Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on May 7, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the claim was submitted upon receiving corrected 
billing information. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until May 13, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99233) provided on May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve six additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that six additional PT visits are medically 
necessary. The Plan denied your request. The Plan says that six additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that six additional physical therapy (PT) visits are medically necessary. Our physician reviewer found that 
clinical documentation shows that the enrollee has not met all appropriate therapy goals due to recent 
hospitalization and 10 visits are appropriate to reach stated goals, thus 6 additional visits is 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 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve six additional physical therapy (PT) visits.  
 
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 a comprehensive oral evaluation (D0150), an additional 
periapical x-ray (D0230), and a panoramic x-ray (D0330) provided on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were pre-approved. The Plan 
denied your request. The Plan says your benefit for the requested items or 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 a panoramic x-ray was exhausted on date of service January 15, 2020, a comprehensive 
oral evaluation was exhausted on date of service January 20, 2020, and periapical x-rays was exhausted on date 
of service February 15, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150), an additional periapical x-ray (D0230), and a panoramic x-ray (D0330) provided on 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and extraction of tooth #14 
(D7210) provided on August 10, 2021. 
 
You asked the Plan to pay for an evaluation and extraction. You say that you needed emergency oral surgery. 
The Plan denied your request. The Plan says a limited oral evaluation (D0140) and extraction (D7210) 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 a limited 
oral evaluation (D0140) and extraction of tooth #14 (D7210) provided on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), ground mileage (A0425), and ambulance oxygen and oxygen supplies (A0422) provided on 
January 21, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that the claim denied as a duplicate. You say 
that the enrollee was transported twice on the date of service. You also say that the claim should be 
reconsidered for payment. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), ground mileage (A0425), and ambulance oxygen and oxygen supplies (A0422) provided on 
January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided by a participating 
provider on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 25, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided by a 
participating provider on March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ViviGen allograft. 
 
You asked the Plan to pre-approve the ViviGen allograft. You say that this is medically necessary for the 
enrollees condition. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
ViviGen cell retaining allograft in the setting of spinal fusion surgery have not been demonstrated in the peer-
reviewed literature. 
 
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 the ViviGen allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the VivGen allograft is experimental. More research is needed when this material is 
used as bone graft.  
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 ViviGen allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ViviGen allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical supplies (A4649) and additional units of tissue 
debridement (11045) provided from October 15, 2021, to December 30, 2021. 
 
You asked the Plan to pay for surgical supplies and additional units of tissue debridement. You say that this 
should be covered. The Plan denied your request. The Plan says records for the billed dates of service were not 
supported.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 surgical supplies (A4649) and 
additional units of tissue debridement (11045) have been met. Medical records for the billed dates of service 
have not been submitted. Therefore, we decided that the Plan does not have to pay for surgical supplies 
(A4649) and additional units of tissue debridement (11045) provided from October 15, 2021, to December 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0150, D0210, D1206, D4342) provided by 
an out-of-network provider on April 11, 2022. 
 
You asked the Plan to pay for 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 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 Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested 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 pay for dental services (D0150, D0210, D1206, D4342) provided by an out-of-network provider on April 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided April 12, 
2022. 
 
You asked the Plan to pay for the oral hygiene instructions. You say that you don't understand why this is not 
covered. The Plan denied your request. The Plan says this service is not covered under your 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 the oral 
hygiene instructions (D1330) provided April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) and a guided tissue 
regeneration (D4267), provided by a participating provider on April 21, 2022. 
 
You asked the Plan to pay for a bone replacement graft and a guided tissue regeneration. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental work 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 a bone 
replacement graft (D7953) and a guided tissue regeneration (D4267), provided by a participating provider on 
April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (maxilla or mandible) 
(D7471) 
 
You asked the Plan to pre-approve the removal of lateral exostosis (maxilla or mandible). You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within 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 
removal of lateral exostosis (maxilla or mandible) (D7471)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (D5730) provided on 
April 6, 2022. 
 
You asked the Plan to pay for the denture. You say that you already paid $100 and received another bill for 
$100. The Plan denied your request. The Plan says the service provided 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 a reline 
complete maxillary denture (D5730) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown fused to predominantly base metal for 
tooth number 19 (D2751). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of this dental 
item. 
 
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. 
 
We looked at the case file and the Plans rules. Based on this information, we have determined that you have 
not met the Plans rules for coverage of this dental item. Specifically, the Plan contract states that porcelain 
crowns are covered once every 60 months for teeth number 4-13 and 20-29. In this case, you have requested a 
porcelain crown for tooth number 19.  Therefore, you do not meet the Plans rules for coverage of this dental item. Therefore, we decided that the 
Plan does not have to pre-approve a porcelain crown fused to predominantly base metal for tooth number 19 
(D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of a torus palatinus (D7472). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal 
of a torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular 
partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures don't fit 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 requested item or service was exhausted on date of service December 15, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and 
mandibular partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), periapical x-
rays (D0230, D0220), and bitewing x-rays (D0274) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says an unspecified preventive procedure (D1999) is not covered by your 
dental benefits. The Plan also says that the denied x-ray codes were bundled and paid as series. 
 
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, an unspecified preventive procedure is 
not among those covered under this benefit. The record shows the denied x-ray codes (D0230, D0220, D0274) 
were bundled and paid as a full mouth x-ray series on this claim. Therefore, we decided that the Plan does not 
have to pay for an unspecified preventive procedure (D1999), periapical x-rays (D0230, D0220), and bitewing 
x-rays (D0274) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - partially bony (D7230), 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922), and 
therapeutic parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pre-approve removal of impacted tooth, intra-socket biological dressing and therapeutic 
parenteral drugs. You say that it is necessary to remove your teeth due to infection. The Plan denied your 
request. The Plan says these services are not covered under your 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 removal of impacted tooth - partially bony (D7230), placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization, per site (D7922), and therapeutic parenteral drugs, two or more 
administrations, different medications (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an out-of-network oral surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that the closest in network oral surgeon was over 
an hour away. You also say that you do not have transportation. 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 a 
consultation with an out-of-network oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2393) provided by an out-
of-network provider on April 4, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not advised that there was a 50% 
coinsurance for these services. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 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 pay more for a resin-based composite (D2393) provided 
by an out-of-network provider on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oroantral fistula closure (D7260), surgical removal of 
implant body (D6100), removal of support implant (20680), and unlisted dental surgery procedure (41899). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services because your 
implant screws are piercing your sinuses. The Plan denied your request. The Plan says these services are 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 pre-approve 
oroantral fistula closure (D7260), surgical removal of implant body (D6100), removal of support implant 
(20680), and unlisted dental surgery procedure (41899).