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

 
We decided that the Plan has to pay for partial denture repair (D5620) provided on February 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had a front tooth pulled. You say that your 
dentist advised you should get a partial to fill the hole. You say that you wanted to have a tooth added to your 
already existing denture. You also say it does not make sense that a new partial would be covered but not the 
addition of a tooth. The Plan denied your request. The Plan says that partial denture repair is not listed as 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. The rules say a plan must 
disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles 
and coinsurance).  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, your contract with the Plan does not 
say in clear and accurate terms the partial denture repair is not covered. Therefore, we decided that the Plan has 
to pay for partial denture repair (D5620) provided on February 16, 2022.  
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of stroke in 2017 and is living at home with weakness. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion office visit to be provided by an OON) provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a second opinion office visit 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 pre-approve a pontic (D6240), and a retainer crown (D6750), 
provided by a participating provider. 
 
You asked the Plan to pre-approve a pontic (D6240), and a retainer crown. You say that you were in the 
hospital for three months. You say that during that time you were unable to pay your bill. The Plan 
denied your request. The Plan says the enrollee is not enrolled. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240), and a 
retainer crown (D6750), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a crown on tooth #4 
(D2740) provided on February 21, 2022. 
 
You asked the Plan to pay for an evaluation and crown. You say that a crown should be covered. The Plan 
denied your request. The Plan says an oral evaluation (D0120-D0180) is covered once every six months. The 
Plan also says that a crown (D2740) is not covered by your Plan's 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. 
 
We looked at this case file, the Plans rules, and Medicare rules. The Plan paid for on oral evaluation provided 
on February 21, 2022; therefore, the benefit for an oral evaluation has been exhausted. Though the Plan offers a 
dental benefit in excess of Medicare coverage, a crown (D2740) is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a crown on 
tooth #4 (D2740) provided on February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure device (LAAC). 
 
You asked the Plan to pre-approve a LAAC. You say that this device is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the Medicare criteria for coverage have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that in order for a left atrial appendage closure device to 
be covered, there must be an apparent contraindication to oral anticoagulation 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 a LAAC. Our reviewer says that this 
device is not medically reasonable and necessary. Our physician reviewer found at issue is the medical 
necessity of implanting a LAAC device in this patient in whom there is elevated risk of thromboembolic stroke 
due to atrial fibrillation and elevated congestive heart failure, hypertension, age 75 (doubled), diabetes, stroke 
(doubled), vascular disease, age 65 to 74 and sex category (female) score. There is no apparent contraindication 
to anticoagulation. As such, guidelines would not support implantation of a LAAC in this setting. In summary, 
LAAC placement would not be considered reasonable or medically necessary in this patients clinical 
management. 
 
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 LAAC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left atrial appendage closure device (LAAC).
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 that you have a past medical history of muscular dystrophy and anemia and is living 
at home with weakness, pain and inability to walk. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis on tooth # 18 and 19 
(D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that these services are medically 
necessary before getting dentures. The Plan denied your request. The Plan says the removal of torus 
mandibularis (D7473) is 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 pre-approve the 
removal of torus mandibularis on tooth # 18 and 19 (D7473).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a left arm fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on February 4, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you are upset that you have to pay for the denied 
services. The Plan denied your request. The Plan says this service is covered by the Plan's dental benefits; 
however, your benefit for one oral evaluation every six months has been exhausted. 
 
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 Plan covers one oral 
evaluation every six months. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for an oral 
evaluation provided on December 14, 2021; therefore, the benefit for an oral evaluation has been exhausted. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on 
February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal adjustment (D9951) provided on February 10, 2022. 
 
You asked the Plan to pay for an occlusal adjustment. You say that you do not understand why the correction 
of the problem was not covered. The Plan denied your request. The Plan says an occlusal adjustment (D9951) 
is 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 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 pay for an 
occlusal adjustment (D9951) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) 
and periodontal scaling and root planing - four or more teeth per quadrant (D4341) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON dental services. You say that you were told that this is a network 
provider. The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 Plan covers crowns and 
periodontal scaling and root planing when the services are rendered by a network provider. 
 We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pre-approve these items/services. Based on this information, we decided that the Plan's rules for 
coverage of a crown and periodontal scaling and root planing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) and periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 21, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (dental code D0150) provided on 
February 18, 2021. 
 
You asked the Plan to pay for a comprehensive oral exam. You say that nobody told you that you would have 
to pay out of pocket for this service. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because one comprehensive examination is covered every 3 plan years and you previously 
received an exam on January 13, 2020. 
 
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 Plan covers one 
comprehensive oral examination every 3 plan years. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received a covered comprehensive 
exam on January 13, 2020; therefore, the benefit was exhausted for date of service February 18, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam (dental code D0150) 
provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 9, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you were unaware the evaluation would not be 
covered. The Plan denied your request. The Plan says this service is covered by your dental benefits; however, 
your benefit for one comprehensive oral evaluation every 36 months has been exhausted. 
 
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 Plan covers one 
comprehensive oral evaluation (D0150) every 36 months. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The Plan paid for a comprehensive oral 
evaluation provided on September 1, 2021; therefore, the benefit for a comprehensive oral evaluation has been 
exhausted. We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed. At this time, the device is not 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that care with the OON home health agency 
is medically necessary. The Plan denied your request. The Plan says there are in-network providers available 
for your medical needs. 
 
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 
home health 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 pre-approve gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's 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 
gingival irrigation  per quadrant (D4921).