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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you would be reimbursed. The 
Plan denied your request. The Plan says your benefit for the requested service has already been exhausted. You 
received code D0140 in August 2021 which means you would not be eligible for this service again until August 
2022. Twelve months had not yet passed between the time you received the service again in May 2022. 
 
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 August 24, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided on June 20, 2022. 
 
You asked the Plan to pay for endodontic therapy, anterior tooth (excluding final restoration) (D3310). The 
Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 
endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and an expandable 
controller harness (E2313). 
 
You asked the Plan to pre-approve an expandable controller and harness. You say that without the expandable 
controller or the harness, the actuators will not function properly as a part of the wheelchair configuration in a 
way that is compliant with the standards that the wheelchair was tested to. Due to this reason, the chair cannot 
be properly ordered or built without those options being added to the power wheelchair. The Plan denied your 
request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2377) and an expandable 
controller harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling & root planing and resin based composite 
(D4341, D2332, D2391, D2393) provided on July 5, 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 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 pay for 
periodontal scaling & root planing and resin based composite (D4341, D2332, D2391, D2393) provided on 
July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (D9985) provided from August 3, 2022, to 
September 13, 2022. 
 
You asked the Plan to pay for the sales tax. You say that you would like your dental coverage to be back dated 
because you were never told it was cancelled. The Plan denied your request. The Plan says the 
predetermination denial of the sales tax is correct, because the sales tax will be revered upon receipt of the 
service being rendered. 
 
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 when it is not processed with a covered service. Therefore, we decided 
that the Plan does not have to pay for sales tax (D9985) provided from August 3, 2022, to September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for services provided from April 9, 2021, to September 10, 2021.
You asked the Plan to pay for these services. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee from April 9, 2021, to September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D3431). 
You say that you are in a lot of pain. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia, anxiolysis (D9230), 
and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on June 22, 2022. 
 
You asked the Plan to pay for inhalation of nitrous oxide/analgesia, anxiolysis (D9230), and extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210). You say that you received the tooth extraction but you don't understand why it was not a 
covered benefit as it was medically necessary. The Plan denied your request. The Plan says these services are 
not covered under the benefit package. 
 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 inhalation 
of nitrous oxide/analgesia, anxiolysis (D9230), and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on June 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth, per 
quadrant (D4342), surgical removal of implant body (D6100) and debridement of a peri-implant defect or 
defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry 
and closure (D6101) provided on December 1, 2021, to December 15, 2021. 
 
You asked the Plan to pay for dental services. You say that the enrollee had numerous periodontal abscesses 
forming around the teeth/implants and that he needed debriding of both teeth and implants. 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. Periodontal scaling and root 
planing - one to three teeth, per quadrant (D4342), surgical removal of implant body (D6100) and debridement 
of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant 
surfaces, including flap entry and closure (D6101) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal scaling and 
root planing - one to three teeth, per quadrant (D4342), surgical removal of implant body (D6100) and 
debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the 
exposed implant surfaces, including flap entry and closure (D6101) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing - one 
to three teeth, per quadrant (D4342), surgical removal of implant body (D6100) and debridement of a peri-
implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, 
including flap entry and closure (D6101) provided on December 1, 2021, to December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on May 23, 2022. 
 
You asked the Plan to pay for a full mouth debridement to enable a comprehensive oral evaluation and 
diagnosis on a subsequent visit (D4355). The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 full 
mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) 
provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling of posterior tooth #17 
(D2391) and a resin-based composite filling of anterior tooth #8 (D2330) provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were not minor and should be 
covered. The Plan denied your request. The Plan says the claim was processed correctly. The fillings you 
received are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 resin-
based composite filling of posterior tooth #17 (D2391) and a resin-based composite filling of anterior tooth #8 
(D2330) provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to pay for a chiropractic visit provided on July 9, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for a chiropractic visit. You say that the provider is in-network with the Plan, but the claim appears to have been processed as out-of-network. The Plan denied your request. The Plan says an authorization was not obtained prior to services rendered.

 
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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for a chiropractic visit provided on July 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted surgical orthopedic procedure 
(0055T). 
 
You asked the Plan to pre-approve a computer-assisted surgical orthopedic procedure. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested services are experimental/investigational. 
 
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 computer-assisted surgical orthopedic 
procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that there are no large volume, long-term/high-quality clinical 
studies that confirm clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 computer-assisted surgical orthopedic procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computer-assisted surgical orthopedic 
procedure (0055T).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that without continued physical therapy the enrollee is in
jeopardy of not being able to regain maximum function and health. Enrollee is currently not able to get in and
out bed by themself, they cannot stand on their own or perform any normal daily activities. The Plan denied
your request. The Plan says the request is not medically necessary, all the services you need are offered at the
IRF. Transfer to a SNF for inpatient skilled rehab services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for car9e in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing
facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allograft procedure for spinal surgery (20930).

You asked the Plan to pre-approve an allograft procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational.

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 allograft procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows osteopromotive-material allograft to be an effective and/or safe treatment for the enrollee's pathology. Further studies are needed to corroborate safety/efficacy over standard allografts. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

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 allograft procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an allograft procedure for spinal surgery (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair resin lower partial denture (D5612x2) provided on 
February 17, 2022, and June 17, 2022. 
 
You asked the Plan to pay for the repair resin lower partial dentures (D5612x2). You say that you should not be 
responsible for the payment amount. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the repair 
resin lower partial denture (D5612x2) provided on February 17, 2022, and June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on May 5, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the evaluation and management service. You say that the service should be covered. The Plan denied your request. The Plan says the services were not urgent or emergent. The Plan also says there were in-network providers available.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body and consultation services 
(D9310, D6010) provided on July 6, 2022. 
 
You asked the Plan to pay for the surgical placement of implant body and consultation services. 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 pay for surgical 
placement of implant body and consultation services (D9310, D6010) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided on 
June 1, 2022. 
 
You asked the Plan to waive the copayment for dental services. You say that you were not aware there would 
be any patient liability. The Plan denied your request. The Plan says the coinsurance is correct. 
 
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. This benefit includes coverage 
of periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274) and 
prophylaxis - adult (D1110) with a $15 copayment per service during the visit for covered routine dental 
services when provided by an in-network provider. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage that covers the requested periodic oral 
evaluation - established patient (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult 
(D1110), there is a $15 copayment ($15/per service x 3 = $45) that was correctly applied to these services. 
Therefore, we decided that the Plan does not have to waive the copayment for periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) 
provided on June 1, 2022.