Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this was denied due to a lack of clinical notes. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the clinical notes 
show no evidence of trauma, degenerative changes of the cervical spine by x-ray, no thoracic spine series, and 
no neurological deficit or dermatome abnormality to imply thoracic spine pathology. Absent any further 
clinical information, the requested MRI of the thoracic spine has not been shown to be medically necessary. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the re-treatment of a previous root canal on tooth #10 
(D3346). 
 
You asked the Plan to pre-approve root canal re-treatment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says that the re-treatment of a previous root canal (D3346) is not 
covered by your dental 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. 
 
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 the 
re-treatment of a previous root canal on tooth #10 (D3346).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 10, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a problem-focused oral exam (D0140) and a cone 
beam computed tomography (CT) scan provided on April 19, 2022. 
 
You asked the Plan to reimburse you for the dental services. You say that you paid for the services and want to 
be refunded. The Plan denied your request. The Plan says your benefit for oral exams has already been 
exhausted and cone beam CT scans are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 oral exam was exhausted on date of service February 22, 2022.  Furthermore, 
the cone beam CT scan is not among the services covered under the supplemental dental benefit. 
Therefore, we decided that the Plan does not have to reimburse you for a problem-focused oral exam (D0140) 
and a cone beam computed tomography (CT) scan provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure (D4273). 
 
You asked the Plan to pre-approve autogenous connective tissue graft procedure. You say that the services are 
medically necessary. The Plan denied your request. The Plan says this procedure is not a covered 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. 
 
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 
autogenous connective tissue graft procedure (D4273).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0367) and a pulp vitality test (D0460) 
provided on April 7, 2022. 
 
You asked the Plan to pay for imaging and a vitality test. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says cone beam imaging (D0367) and a pulp vitality test 
(D0460) are not covered by your routine dental 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. 
 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 cone 
beam imaging (D0367) and a pulp vitality test (D0460) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), limited oral 
evaluation (D0140), and the surgical removal of an erupted tooth (D7210) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. Additionally, a panoramic 
radiographic image and the surgical removal of an erupted tooth are not covered under your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services are not covered under this benefit when 
received from an out-of-network provider. Additionally, a panoramic radiographic image and the surgical 
removal of an erupted tooth are not covered under your contractual policy.  Therefore, we decided that the 
Plan does not have to pay for the panoramic radiographic image (D0330), limited oral evaluation 
(D0140), and the surgical removal of an erupted tooth (D7210) provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade identified with code 
E2377, harness for upgrade to expandable controller identified with code E2313, power seat elevation system 
identified with code E2300, and electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311. 
 
You asked the Plan to pre-approve expandable controller upgrade, harness for upgrade to expandable 
controller, power seat elevation system, and electronic connection between wheelchair controller and two or 
more power seating system motors. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature is non-covered. 
 
Review of the file shows that there is no medical need to control the requested power options through the 
joystick. The enrollees upper limb strength and function are adequate for the enrollee to be able to control the 
power options using their own switches which are included in the allowance of the approved power options. 
The requested power seat elevation system is specifically not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of expandable controller upgrade, harness for upgrade to expandable controller, power seat elevation 
system, and electronic connection between wheelchair controller and two or more power seating system motors 
have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller 
upgrade identified with code E2377, harness for upgrade to expandable controller identified with code E2313, 
power seat elevation system identified with code E2300, and electronic connection between wheelchair 
controller and two or more power seating system motors identified with code E2311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, and 11. 
 
You asked the Plan to pre-approve the crowns. You say that the previous crowns you received were done 
terribly and you would like them to be replaced. The Plan denied your request. The Plan says your benefit for 
the requested services 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 services was exhausted on date of service July 22, 2021. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - upper (D5110) and complete 
denture - lower (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentist messed your teeth up 
and didn't do your dentures properly. 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 upper and lower denture was exhausted on date of service April 29, 2021. Therefore, 
we decided that the Plan does not have to pre-approve complete denture - upper (D5110) and complete denture 
- lower (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is very medically complex. The enrollee 
needs a heart procedure done but the doctor recommends rehabilitation first to get better before the procedure. 
The Plan denied your request. The Plan says admission to the IRF was denied as not meeting acute inpatient 
rehabilitation criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled 
nursing facility level of care was offered. 
 
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 enrollee with coronary artery disease and aortic stenosis is deconditioned 
following an acute illness including cardiac catheterization. The enrollee is Min A for walking and transfers 
including toilet transfers. The enrollee does not require intensive rehabilitation services and does not require 
frequent physiatry oversight or rehabilitation nursing. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 5, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D5213, D5214) on March 28, 2022. 
 
You asked the Plan to pay for dental services (D5213, D5214). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services are not covered 
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. 
 
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 dental 
services (D5213, D5214) on March 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic radiographic 
image (D0330), the extractions of an erupted tooth or exposed root (D7140 X 6), and the immediate upper 
denture (D5130) provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and 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 Plan's coverage rules apply in this case. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140), panoramic radiographic image (D0330), the extractions of an erupted tooth or 
exposed root (D7140 X 6), and the immediate upper denture (D5130) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392 X 2) 
provided on March 10, 2022. 
 
You asked the Plan to pay for the composites. You say that you were misinformed about your dental coverage. 
The Plan denied your request. The Plan says this procedure is not covered under your dental 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 resin-
based composite - two surfaces, posterior (D2392 X 2) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #24 and 25 (D2740). 
 
You asked the Plan to pre-approve crowns. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says that services in this arch have a questionable long-term result. 
 
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. The Plan did not provide the clear medical records that were used in making 
their decision. The Plan has not supported their decision to deny your request. Therefore, we decided that the 
Plan has to pre-approve a crown on tooth #24 and 25 (D2740).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental service (D0431) on March 24, 2022. 
 
You asked the Plan to pay for dental service (D0431). You say that you would like to appeal the denial of the 
claim and that you were told the service was covered. The Plan denied your request. The Plan says dental 
service (D0431) in question is not covered under the Member's contract under any normal circumstances. 
 
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 dental 
service (D0431) on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), or pay more for the 
two periodontal scalings and root planings of four or more teeth per quadrant (D4341 x2), and two periodontal 
scalings and root planings of one to three teeth per quadrant (D4342 x2) provided on April 12, 2022. 
 
You asked the Plan to pay for the gingival irrigations and to pay more for the scalings and planings. You say 
that the provider you were treated by was listed as in-network on the Plan's website. The Plan denied your 
request. The Plan says the gingival irrigations are not a covered expense under your dental plan. The Plan also 
says that you must pay a $25 copay for each scaling and planing.  
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, gingival irrigation (D4921) is not 
among those covered under this benefit. The contract also clearly states that you are responsible for a $25 
copayment for each periodontal scaling and root planing that is rendered by an in-network provider. Therefore, 
we decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4), or pay more for the 
two periodontal scalings and root planings of four or more teeth per quadrant (D4341 x2), and two periodontal 
scalings and root planings of one to three teeth per quadrant (D4342 x2) provided on April 12, 2022.