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

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and 
panoramic x-ray (D0330) provided on December 15, 2021 by an out-of-network (OON) provider. You asked the Plan to pay for the 2D oral/facial photographic images, comprehensive oral evaluation, complete 
series of intraoral x-rays, and panoramic x-ray. The Plan denied your request. The Plan says 2D oral/facial 
photographic image is not a covered expense under your dental plan. The Plan also says that services 
performed by an OON provider are not covered because your healthcare plan does not have OON 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, 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract also says that you are responsible for 
100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does 
not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4), comprehensive 
oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided 
on December 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that last year you were approved for 
a partial denture, and you need another for a lower partial. The Plan denied your request. The Plan says this 
service is not covered 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 pre-approve a 
mandibular partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on November 24, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that this service should not have been denied. The 
Plan denied your request. The Plan says this service is not a covered benefit 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 the 
surgical placement of implant body: endosteal implant (D6010) provided on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), and 5 simple extractions 
(D7140) provided on November 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed for the dental 
services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services received from a provider that has opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the surgical extraction (D7210), and 5 simple extractions (D7140) 
provided on November 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health skilled nursing visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. Provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate skilled nursing visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing visits.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and more stable and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment has completed. 
 
 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 consultation (D9310) or pay more for the removal of 
residual tooth roots (D7250) provided on July 9, 2021. 
 
You asked the Plan to pay for the consultation and to pay more for the removal of residual tooth roots. You say 
that you are not taking responsibility for the check that was made out to you, as it is the Plan's mistake. You 
also say that your low income cannot afford it. The Plan denied your request. The Plan says this claim has been 
processed correctly according to your plan 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. 
Though the Plan offers a dental benefit in excess of Medicare coverage, consultation (D9310) is not among 
those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for the 
removal of residual tooth roots (D7250). Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) or pay more for the removal of residual tooth roots (D7250) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0367) 
provided on November 18, 2021. 
 
You asked the Plan to pay for the cone beam CT. You say that the type of x-ray that you received was 
necessary to have your root canal done. You also say that this service should be covered. The Plan denied your 
request. The Plan says cone beam CT is not a covered dental 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 cone beam CT is not among those covered under this benefit. Additionally, the record shows that you signed a financial agreement stating you 
would be responsible for non-covered charges. Therefore, we decided that the Plan does not have to pay for the 
cone beam computed tomography (CT) (D0367) provided on November 18, 2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON SNF services. You say that your husband has dementia and had to 
be moved to this requested OON facility. You say that you agreed to have him moved as long as you were able 
to go with him. The Plan denied your request. The Plan says there are network SNFs that can provide the 
services needed. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on July 23, 2021. 
 
You asked the Plan to pay for the bone replacement graft. You say that you believe this service should be 
reviewed again due to the necessity of needing bone in your jaw. The Plan denied your request. The Plan says 
this service is not covered. 
 
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 bone 
replacement graft for ridge preservation (D7953) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you have diabetes, have 
suffered 3 strokes and have tooth sensitivity. You say that you are in pain and cannot take much pain 
medication. The Plan denied your request. The Plan says services must be performed by a participating general 
dentist. 
 
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, dental services provided by an oral 
surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve a comprehensive oral evaluation to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were experiencing excruciating pain in your 
mouth. You say that you were referred to this provider. You also say that this service was necessary to 
determine if you would need a root canal. The Plan denied your request. The Plan says 1 limited oral evaluation 
is covered per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on November 23, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crown. You say that you were told 
that your plan would cover this service. The Plan denied your request. The Plan says this service is not covered 
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 pre-approve an 
implant supported porcelain/ceramic crown (D6065).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Intracept procedure. 
 
You asked the Plan to pre-approve a Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two prefabricated abutments (D6056 x2), and two implant supported porcelain/ceramic 
crowns (D6065 x2). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported 
porcelain/ceramic crowns. 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 Plan's 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056 
x2), and two implant supported porcelain/ceramic crowns (D6065 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says that you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and post and core in addition to crown 
(D2952). 
 
You asked the Plan to pre-approve the crown and post and core. You say that your crown broke and a root 
canal is not necessary. The Plan denied your request. The Plan says multiple verbal and written outreaches 
were made to your dental provider for x-rays to be reviewed for medical necessity. The Plan also says that the 
x-rays were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a crown (D2740) and post and core in 
addition to crown (D2952). have been met. A copy of the applicable digital quality x-rays was not submitted 
for this case. The Plan made multiple attempts asking for x-rays, but they were not provided. Without these x-
rays we are unable to determine if these services are medically reasonable and necessary. Therefore, we 
decided that the Plan does not have to pre-approve a crown (D2740) and post and core in addition to crown 
(D2952).