Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture - flexible base (D5225). 
 
You asked the Plan to pay for the dental services. You say that its hard to chew and you need to have this done. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 10, 2019. Therefore, 
we decided that the Plan does not have to pay for maxillary partial denture - flexible base (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visits and injections provided 
from April 20, 2023, to May 4, 2023. 
 
You asked the Plan to waive the copayment for specialist visits and injections. You say that you were told you 
would be charged $127.99, which covered the medications and the actual injections. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for a Medicare Part B prescription drug.  You have been asked to pay $186.03 for specialist visits and injections. This total includes $66.03, which is 
20% of the allowed amount for three Medicare Part B drug injections ($110.05 allowed x 20% = $22.01 per 
injection x 3 injections = $66.03), and a $120 for three specialist visits ($40 per visit x 3 = $120). The 
injections fall within the Medicare Part B prescription drug benefit category. The specialist visits fall within the 
physician/practitioner services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
specialist visits and injections provided from April 20, 2023, to May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953). 
 
You asked the Plan to pre-approve bone replacement graft. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for frames (V2020) and spherocylinder, trifocal lenses (V2303) 
provided on April 26, 2023. 
 
You asked the Plan to pay more for frames (V2020) and spherocylinder, trifocal lenses (V2303). You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says that an appeal was 
submitted with no new documentation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is no evidence that the Plan specifically requested the written order after 
the appeal was submitted. The Plan did not do their due diligence. Therefore, we decided that the Plan has to 
pay more for frames (V2020) and spherocylinder, trifocal lenses (V2303) provided on April 26, 2023.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you are having surgery and need help with 
home care. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home 
aide services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), an adult 
prophylaxis (D1110) and an occlusal guard (D9944) provided on August 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you need this. You also say you were 
getting terrible headaches and sick to your stomach from pain, until this provider recommended it. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount for a periodic oral evaluation (D0120), and an adult prophylaxis (D1110) when your services are 
received from an out-of-network provider. The Plan also says that an occlusal guard (D9944) is excluded from 
this benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for a periodic oral evaluation (D0120), and an adult prophylaxis (D1110). This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Also, though the Plan offers a dental 
benefit in excess of Medicare coverage, an occlusal guard are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), an adult 
prophylaxis (D1110) and an occlusal guard (D9944) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve teeth extractions under anesthesia in a medical setting. 
 
You asked the Plan to pre-approve teeth extractions under anesthesia in a medical setting. You say that due to a 
neurology issue the services need to be done in a hospital setting. The Plan denied your request. The Plan says 
this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve teeth 
extractions under anesthesia in a medical setting.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan (D0367). 
 
You asked the Plan to pre-approve CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve CT 
scan (D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments to be rendered by the out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are available with an  
in-network provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture treatments to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 29, 2023 and 
August 8, 2023. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation 
(D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D7956) provided on May 25, 
2023. We also decided that the Plan does not have to waive the coinsurance for a tooth extraction (D7210) and 
a bone replacement graft for ridge preservation (D7953) also provided on May 26, 2023. 
 
You asked the Plan to pay for guided tissue regeneration (D7956). You also asked the Plan to waive the 
coinsurance for a tooth extraction (D7210) and a bone replacement graft for ridge preservation (D7953). You 
say that no mention was made by the provider about submitting a request for summary of benefits for specific 
services ahead of time. You also say you were told this would be necessary to fill in space and healing time 
would be needed. The Plan denied your request. The Plan says guided tissue regeneration (D7956) is not listed 
as covered code for the optional dental coverage. The Plan says the cost sharing for a tooth extraction (D7210) 
and a bone replacement graft for ridge preservation (D7953) was charged correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, guided tissue regeneration (D7956) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
guided tissue regeneration (D7956) provided on May 25, 2023.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for the extraction of an erupted tooth or exposed root (D7210) and bone replacement grafts for 
ridge preservation (D7953). 
 
You have been asked to pay $108 in coinsurance, which is 50% of the allowed amount for a tooth extraction 
(D7210) ($216 x 50% = $108). You have also been asked to pay $262.50 in coinsurance, which is 50% of the 
allowed amount for a bone replacement graft for ridge preservation (D7953) ($525 x 50% = $262.50). These 
services fall within the oral and maxillofacial surgery benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a tooth extraction (D7210) and a bone replacement graft for ridge preservation (D7953) also 
provided on May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary 
for your recovery. The Plan denied your request. The Plan says the services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that that the IRF admission is medically necessary. The 
Plan denied your request. The Plan says you do not meet the criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF as medically necessary care 
can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment that includes placement 
(D6057) for tooth number 13. 
 
You asked the Plan to pre-approve the dental services. You say that the lack of this crown makes it difficult for 
you to eat. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested authorization for custom fabricated abutment that includes placement 
(D6057) was exhausted on date of service May 26, 2023. Therefore, we decided that the Plan does not have to 
pre-approve custom fabricated abutment that includes placement (D6057) for tooth number 13.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 12, 2023. 
 You asked the Plan to pay for the office visit. You say that you were advised that the claim would be covered. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on May 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 21, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication should be covered. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on April 21, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth 2, 4, 6, 9, 10, 11, 
14, 19, 21, 23, 25, 27 and 29; prefabricated abutment (D6056) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 
and 29; and abutment supported porcelain fused to metal crown (D6059) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 
23, 25, 27 and 29. 
 
  You asked the Plan to pre-approve implant placement (D6010) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 
and 29; prefabricated abutment (D6056) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 and 29; and abutment 
supported porcelain fused to metal crown (D6059) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 and 29. You 
say that you wanted to submit an appeal due to your dental health condition. You also say you cannot eat well. 
The Plan denied your request. The Plan says these services are not  covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 and 29; prefabricated abutment 
(D6056) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 and 29; and abutment supported porcelain fused to 
metal crown (D6059) for teeth 2, 4, 6, 9, 10, 11, 14, 19, 21, 23, 25, 27 and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service March 17, 
2023.  
 You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service March 17, 2023.