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

 
We decided that the Plan does not have to pay for the endodontic therapy (D3310), anterior resin-based 
composite (D2330), and posterior resin-based composite (D2391) provided on July 23, 2021, and August 5, 
2021. 
 
You asked the Plan to pay for the endodontic therapy and resin-based composites. You say that you felt tricked, 
taken advantage of, and violated with malicious intent in performed a root canal without your knowledge and 
consent. You also say that you will not be seeing this provider anymore. The Plan denied your request. The 
Plan says the endodontic therapy is not a covered expense under your dental plan. The Plan also says that your 
benefits for the resin-based composites has been satisfied and the frequency limitation 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 Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, endodontic therapy (D3310) is not 
among those covered under this benefit. The contract says that restorations are limited to two procedure codes 
per calendar year. The record shows that you received one anterior resin-based composite (D2330) on August 
5, 2021 and one posterior resin-based composite (D2391) on July 23, 2021 which were covered by the Plan and 
your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3310), anterior resin-based composite (D2330), and posterior resin-based composite 
(D2391) provided on July 23, 2021, and August 5, 2021.  
 
Your complaint about possibly being tricked into getting a root canal without your knowledge or consent is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470). 
 
You asked the Plan to pre-approve diagnostic casts. You say that you had out-of-network care approved. 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 pre-approve 
diagnostic casts (D0470).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) additional physical therapy (PT) visits 
(97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria.  
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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the available records, you have not made significant progress 
with the 17 therapy visits thus far and it is not clear that the 14 additional visits are medically necessary. 
Provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled therapy visits beyond what have already been approved. 
Additional therapy services will be re-evaluated again after completion of the two additional visits recently 
approved. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve fourteen (14) additional physical therapy (PT) visits (97110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010) for teeth 6, 8, 9, and 11. 
 
You asked the Plan to pre-approve the dental services. You say that you really need the implants. You also say 
that you cannot eat very well and are in pain. The Plan denied your request. The Plan says implants are 
specifically excluded from coverage. 
 
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 implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants 
(D6010) for teeth 6, 8, 9, and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), fixed partial denture repair (D6980), extraction (D7210), evaluation for moderate sedation (D9219), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) provided on March 24, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the dental services. You say that you would like to appeal these services. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds.
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 the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), fixed partial denture repair (D6980), extraction (D7210), evaluation for moderate sedation (D9219), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) provided on March 24, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission for the approved Anterior lumbar 
interbody fusion (ALIF). 
 
You asked the Plan to pre-approve an inpatient admission. You say that the requested inpatient admission for 
the approved Anterior lumbar interbody fusion (ALIF) is medically necessary. The Plan denied your request. 
The Plan says the requested inpatient admission for the approved Anterior lumbar interbody fusion (ALIF) 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 an inpatient admission. Our reviewer 
says that the requested inpatient admission for the approved Anterior lumbar interbody fusion (ALIF) is not 
medically necessary. Our physician reviewer found inpatient admission is not needed after this ALIF surgery. 
The case can safely be performed as an observational 48 hour stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission for the approved Anterior lumbar interbody fusion (ALIF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5650) 
provided on September 23, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had a tooth pulled. You say that you had no 
tooth to hold your partial. You say that you finally got to your dentist. You also say that you had a cleaning and 
tooth repair so you could wear your partial. The Plan denied your request. The Plan says the addition of a tooth 
to an existing denture 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the addition of a tooth to an existing denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the addition of a tooth to an existing partial denture (D5650) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on September 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that 
the book said there were no copays plus 2 visits not to exceed $500, no in-network needed. You also say that 
you would like the full amount charged to be paid. The Plan denied your request. The Plan says the total 
$125.00 amount applied correctly as OON member liability. The Plan also says that cost sharing is a 
contractual obligation under the Plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount because these services were received OON. Therefore, we 
decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on September 8, 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 comprehensive oral exam (D0150) and a surgical 
extraction (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental exam and extraction. You say that these services are necessary, 
and you want to go back to the provider who initially extracted these teeth. The Plan denied your request. The 
Plan says services must be provided by a participating general dentist. Services from a dental specialist, such as 
an oral surgeon, are not covered. In addition, the Plan says that their records do not reflect that you have been 
evaluated by a participating general dentist to order these services. You have not seen a dentist since 2019. 
 
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 requires 
supplemental dental care be provided by a participating general dentist. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, items or services performed by an oral 
surgeon are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral exam (D0150) and a surgical extraction (D7210) 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 comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on October 27, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you were under the impression that by switching policies you were starting over on dental coverage and claims due to being insured under a new policy. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have 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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years, and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on January 17, 2019 and your comprehensive oral evaluation (D0150) and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections at a third level. 
 
You asked the Plan to pre-approve facet joint injections at a third level. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is no special need for a three-level session. 
 
The Plan must follow Medicare rules. Medicare rules say that three or four-level procedure performed the same 
day may be considered under unique circumstances.  
 
 
 
 
 We looked at the file and Medicare rules. In this case, there is no unique circumstances that would allow three 
levels to be performed in one day. Based on this information, we decided that Medicare rules for coverage of 
facet joint injections at a third level have not been met. Therefore, we decided that the Plan does not have to 
pre-approve facet joint injections at a third level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that your gums bleed when you brush your 
teeth. You say that you are on blood thinners. You also say that you are not able to pay for these services out of 
pocket. The Plan denied your request. The Plan says scaling and root planing is covered once per quadrant 
every 36 months. The Plan also says that the frequency limit has been reached. 
 
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 and scaling and root planing is listed as 
covered, the frequency limit of once per quadrant every 36 months has been exceeded. The record shows that 
the Plan paid for scaling and root planing for the upper right and lower right quadrant that you received on August 7, 2019. The record shows that the Plan paid for scaling and root planing for the upper left and lower 
left quadrants you received on August 14, 2019. Therefore, we decided that the Plan does not have to pre-
approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on November 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the hospital services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were not rendered or referred by a network provider, nor were they rendered in an in-network facility. The Plan also says that the services were 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hospital services provided on November 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standing frame/table system (E0638) provided on 
December 23, 2020. 
 
You asked the Plan to pay for a standing frame/table system. You say that you were instructed by a 
representative of the Plan to make the purchase and told that you would be reimbursed 80%. The Plan denied 
your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a standing frame/table system (E0638) provided on December 23, 2020.  
 
Your complaint about receiving erroneous or incomplete information about your benefits from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the upper right, 
upper left, lower right, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the enrollee has generalized 
periodontal pocketing over 5mm, sub-gingival tartar accumulations clearly on roots visible on bitewing 
radiographs plus vertical bone loss. The Plan denied your request. The Plan says that this request is not 
medically necessary. 
 
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 the scalings 
and planings when the services are medically necessary and reasonable. 
 
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 scalings and planings. Our reviewer 
says that the documentation meets the criteria for coverage for periodontal scaling and root planing (D4341) in 
four quadrants. Our physician reviewer found that pathological periodontal pockets of 5 to 7mm are present in 
all quadrants and areas of bone loss are present. Our reviewer also found that periodontal scaling and root 
planing is medically necessary and reasonable to treat the patient's periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have been met. Therefore, we decided that the Plan 
has to pre-approve periodontal scalings and root planings (D4341) of the upper right, upper left, lower right, 
and lower left quadrants.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine stress test provided on 
July 28, 2021. 
 
You asked the Plan to waive the copayment for a nuclear medicine stress test. You say that the Plan should pay 
for the test. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $495 
copayment for nuclear medicine services at an outpatient hospital.  
 
You have been asked to pay a $495 copayment for a nuclear medicine stress test. A nuclear medicine stress test 
falls within the Outpatient Diagnostic Tests and Therapeutic Services And Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a nuclear medicine stress test provided on July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one. 
 
You asked the Plan to pre-approve Synvisc-one. You say that the requested Synvisc-one injection is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa, Supartz FX, 
Durolane, and Gelsyn-3 first. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc-one. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one.