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

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011) Tooth #4 and 13. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested services. 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. This benefit includes the 
requested item or service but is limited to implants: up to two implants covered per year, or up to four implants 
covered per year for edentulous patients. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered surgical access to an implant body (second stage implant surgery) (D6011) Tooth 
#6, 11, 22 and 27 on date of service July 18, 2023. Therefore, this benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve surgical access to an implant body (second stage implant 
surgery) (D6011) Tooth #4 and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network dermatology procedure 
provided on March 3, 2023. 
 
You asked the Plan to waive the copayment for an in-network dermatology procedure. You say that you were 
not treated properly by this facility and had a hard time even knowing what treatment to do. This needs to be 
addressed, and you feel you should not have to pay this large copayment. 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 a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical facilities.   
You have been asked to pay the allowed amount of $274.48 which is less than the $350 copayment for an in-
network dermatology procedure. This item/service falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical facilities 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 an in-network dermatology procedure provided on March 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network colonoscopy provided on 
March 22, 2023. 
 
You asked the Plan to waive the copayment for an in-network colonoscopy. You say that you were not aware 
that there was copayment for this test. 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 a $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $300 copayment for an in-network colonoscopy. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 an in-network colonoscopy 
provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on March 31, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that you would like to request 
reconsideration for the denied services. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chronic care 
management services provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (5110). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied denture. 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 the Plan paid for a partial upper denture (D5213) on April 5, 2022; therefore, the enrollees benefit for 
the requested item or service was exhausted on the date of service of April 5, 2022. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and retainer crowns (D6740) for tooth 
#3, #4, and #5. 
 You asked the Plan to pre-approve the dental services. You say that crown repairs should be covered by the 
Plan. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because pontics and retainer crowns are not covered by the 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 a 
pontic (D6245) and retainer crowns (D6740) for tooth #3, #4, and #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve the pontic - porcelain/ceramic. The Plan denied your request. The Plan says 
your benefit for the requested item or service $2,250 dollar limit was met. 
 
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 the Plan approved the requested services up to your benefit limit at the time of this request. You had 
previously used $17.00 on June 29, 2023 for dental code D0220. The allowed amount for the services 
requested for this authorization would be $2,552.00 + $17.00 = $2,569.00). This leaves you responsible for 
$319.00 for dental code D6245. Therefore, we decided that the Plan does not have to pre-approve a pontic - 
porcelain/ceramic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that you need this to help your bones 
grow after your scheduled spinal surgery and you also have underlying health conditions. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 the osteogenesis stimulator. Our 
physician reviewer found it is only a 2-level fusion and not enough time has passed to establish a nonunion. 
More time is needed- at least 9 months. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the osteogenesis stimulator (E0748).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on October 27, 2022. 
 
You asked the Plan to pay for an occlusal guard (D9944). You say that this charge is not for dental related 
services. This is an appliance to treat sleep apnea. The Plan denied your request. The Plan says these dental 
related services are excluded from coverage under your 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 pay for an 
occlusal guard (D9944) provided on October 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 16, 2023, to April 21, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that you do not agree with the denial of payment for 
the services you received. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on March 16, 2023, to April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  retainer crown - porcelain/ceramic (D6740 x5) and core 
buildup, including any pins when required (D2950 x5). 
 
You asked the Plan to pre-approve  retainer crown and core buildup. You say that this should be covered. 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  
retainer crown - porcelain/ceramic (D6740 x5) and core buildup, including any pins when required (D2950 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 3), abutment supported porcelain/ceramic crowns (D6058 x 3), and custom fabricated 
abutments-includes placement (D6057 x 3). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested items/services 
are not covered under the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of an implant body: endosteal implants (D6010 x 3), abutment supported porcelain/ceramic 
crowns (D6058 x 3), and custom fabricated abutments-includes placement (D6057 x 3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services performed on February 3, 2023, coded 
as 74240, 74230, 72040, 70100, 70310, and 71045. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services performed on 
February 3, 2023, should be paid as billed.  The Plan denied your request. The Plan says the radiology services 
described by codes 74240 and 74230 are not covered benefits because they are listed in the Exclusions from 
Coverage as Portable X-Ray Services section of the Medicare Benefit Policy Manual. Radiology services 
described by codes 72040, 70100, 70310, and 71045 were billed with an inappropriate place of service.  
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, 70310, and 71045 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services performed on February 3, 2023, coded as 74240, 
74230, 72040, 70100, 70310, and 71045.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant (D6010), prefabricated abutment 
(D6057), abutment supported crown (D6058), and a bone graft (D6104). 
 
You asked the Plan to pre-approve dental implant, prefabricated abutment, abutment supported crown, and a 
bone graft. You say that this should be covered. 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 dental implant (D6010), prefabricated abutment (D6057), abutment supported crown (D6058), and a bone graft 
(D6104).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee deserves an opportunity to 
complete their full recovery in an environment which offers a wide range of comprehensive services. The Plan 
denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) and 
periodontal scaling and root planing (D4342) for the lower level and the lower right quadrants provided on 
January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services were prescribed for initial 
treatment and support for treatment to your non-curable, chronic periodontal infection. 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 January 3, 2023, and 
January 23, 2023. Therefore, we decided that the Plan does not have to pay for the localized delivery of 
antimicrobial agents (D4381) and periodontal scaling and root planing (D4342) for the lower level and the 
lower right quadrants provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fundus photography and a medical eye 
examination provided on May 9, 2023. 
 
You asked the Plan to waive the copayment for fundus photography and a medical eye examination. You say 
that you were told your copayment was $15 at check in, which you paid at the time of service. You also say 
you received a bill for a $30 extra copayment from the provider. 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 a $30 
copayment for each outpatient x-ray, diagnostic procedure and test. Your contract with the Plan also says that 
you must pay a $15 copayment for Medicare-covered examination (diagnosis and treatment for diseases and 
conditions of the eye)diseases and conditions of the eye).  
 
You have been asked to pay a $30 copayment for fundus photography. This item/service falls within the 
outpatient x-ray, diagnostic procedure and test benefit category. You have also been asked to pay a $15 
copayment for a medical eye examination. This item/service falls within the Medicare-covered examination 
(diagnosis and treatment for diseases and conditions of the eye) 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 fundus photography and a medical eye examination provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of gingival inflammation (D4346) 
and medicaments (D9630) provided by on March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand the denial and you 
thought the dental services would be covered by the Plan. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the scaling in presence of gingival inflammation and 
medicaments are not covered by the 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 pay for the 
scaling in presence of gingival inflammation (D4346) and medicaments (D9630) provided by on March 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical additional radiographic image 
(D0230) provided on May 15, 2023. 
 
You asked the Plan to pay for the dental service. You say that you need the radiographic image to be approved. 
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 the date of service of May 15, 2023. 
Therefore, we decided that the Plan does not have to pay for the intraoral periapical additional radiographic 
image (D0230) provided on May 15, 2023.