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

 
We decided that the Plan does not have to pay for the inhalation of nitrous/analgesia, anxiolysis on April 11, 
2022, and April 18, 2022. 
 
You asked the Plan to pay for the inhalation of nitrous/analgesia, anxiolysis. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the service was 
denied as a non-covered Medicare 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 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 
inhalation of nitrous/analgesia, anxiolysis on April 11, 2022, and April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 17, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. The rendering dentist is not a participating provider. Based on this 
information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services provided by an out-of-network provider on March 
17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial denture fix (D6930) provided by an out-of-network 
provider on October 27, 2021. 
 
You asked the Plan to pay for partial denture fix. You say that these services were necessary. The Plan denied 
your request. The Plan says they pay up to $1,000 every year for non-Medicare comprehensive dental services. 
 
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 up to $1,000 
every year for non-Medicare comprehensive dental services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of partial denture fix have not been met. Therefore, we decided that the Plan does not have to pay for 
partial denture fix (D6930) provided by an out-of-network provider on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and panoramic 
imaging (D0330), provided by a participating provider on February 16, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and panoramic imaging. You say that these 
services were necessary. The Plan denied your request. The Plan says the benefit limit for the services provided 
have already been met and 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. The Plan covers one 
comprehensive oral evaluation and one panoramic imaging once every three years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and panoramic imaging have not been met. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and panoramic imaging 
(D0330), provided by a participating provider on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings x-rays 
(D0274), and prophylaxis (D1110) provided on March 10, 2022. 
 
You asked the Plan to pay for an evaluation, x-rays, and prophylaxis. You say that you have seen this provider 
previously and the services were paid. The Plan denied your request. The Plan says the services are not covered 
when seen by 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 Plan's coverage rules apply in this case. 
 
The record shows you received 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 by an out-of-network provider. Therefore, we decided that the Plan does not have to pay 
for a periodic oral evaluation (D0120), bitewings x-rays (D0274), and prophylaxis (D1110) provided on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81238, 81225, 81230, 81241, 
81291, 81240) provided on August 24, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81238, 81225, 81230, 81241, 81291, 81240) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation on December 13, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says according to your benefits limited oral exams are allowed 
once per year and you have used this benefit in the past year. The plans records show that these services were 
received on July 28, 2021. 
 
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 
among those covered under this benefit, however, just once per plan year. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation on December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura cream. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed for the enrollee's 
condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura cream.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction on tooth #9 (D7140), an addition to partial 
denture on tooth # 8 and 9 (D5650), post and core in addition to crown on tooth #10 (D2952), and a crown on 
tooth #10 (D2740) provided on January 11, 2022. 
 
You asked the Plan to pay for an extraction, addition to denture, and crowns. You say that you have seen this 
provider in the past and the services have always been covered. The Plan denied your request. The Plan says 
the services are not covered when seen by 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. 
 
 The record shows you received 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 among those covered 
under this benefit when seen by an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction on tooth #9 (D7140), an addition to partial denture on tooth # 8 and 9 (D5650), post 
and core in addition to crown on tooth #10 (D2952), and a crown on tooth #10 (D2740) provided on January 
11, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as in a skilled nursing facility. 
 
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 while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services an IRF would provide. 
 
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 the maxillary partial denture (D5213) provided on March 23, 2022. 
 
You asked the Plan to pay for the partial denture. You say that you were never able to use the partial denture 
you received in November of 2017. Since the new partial denture was provided only a few months early, you 
asked for it to be covered by the Plan. The Plan denied your request. The Plan says you received a partial 
denture in November of 2017, therefore 60 months have not passed prior to you receiving a new partial denture 
on March 23, 2022. 
 
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 the partial 
denture once every 60 months when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we found that 60 months had not passed 
prior to you receiving a new partial denture. Therefore, we decided that the Plan does not have to pay for the 
maxillary partial denture (D5213) provided on March 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate level of 
care for this enrollee and the enrollee is medically stable to be transferred to LTACH level of care. The Plan 
denied your request. The Plan says authorization denied because the LTACH was not medically necessary, and 
the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation (dental code D0120) and a dental cleaning 
(dental code D1110) provided on December 21, 2021. 
 
You asked the Plan to pay for an evaluation and a dental cleaning. You say that you were unaware that you hit 
your maximum in dental benefits and would have waited until the next year for the appointment. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because you received 
covered dental services on April 20, 2021, for $106 and on May 12, 2021, for $394; therefore, the $500 
allowance per calendar year was met prior to the date of service. 
  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 preventive 
and comprehensive services up to a $500 allowance per calendar year. On April 20, 2021, the total covered 
dental service was $106. On May 12, 2021, the total covered dental service was $394 bringing the maximum 
allowance of covered dental services to $500 ($106 covered dental + $394 covered dental) 
 
We looked at the file, the Plan's rules, and Medicare rules. You previously received covered dental services on 
April 20, 2021, and on May 12, 2021; therefore, the benefit was exhausted for date of service December 21, 
2021. Therefore, we decided that the Plan does not have to pay for an evaluation (dental code D0120) and a 
dental cleaning (dental code D1110) provided on December 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care to 
be provided by a network provider. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says authorization denied because the 
continuation of the SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care 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 the continuation of SNF care. Our 
reviewer says that the continuation of SNF care is not medically necessary. Our physician reviewer found there 
are no identifiable skilled nursing service needs that require skilled nursing services, including the specialized 
skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide 
medically necessary and reasonable treatment. There are no identifiable skilled therapy service needs that 
require skilled therapy services, including the specialized skill, knowledge and judgment of a qualified 
therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee 
does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care to be provided by a 
network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that you want to improve your quality of life and you 
need physical therapy to get stronger. You say you need to be able to safely transfer from bed to your 
wheelchair. The Plan denied your request. The Plan says authorization denied because the SNF care is not 
medically necessary and your needs can be met at a lower level of care such as home, a long-term care facility 
or other outpatient location. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care 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 the SNF care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are no identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. You do not require skilled nursing or therapy services on a daily 
basis. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (D0150) provided by a network 
provider on February 22, 2022. 
 
You asked the Plan to pay for the comprehensive oral examination (D0150). You say that the comprehensive 
oral exam that you had in 2021 was unnecessary because you were extremely dissatisfied with the dentures you 
received at that appointment. The Plan denied your request. The Plan says the service exceeded the frequency 
limitation in the benefit 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 Plan also has a maximum benefit 
of one comprehensive exam procedure every three plan years. The requested services are not covered because 
the Plan paid for a comprehensive exam on November 7, 2021, which exhausted your benefit. Therefore, we 
decided that the Plan does not have to pay for the comprehensive exam (D0150) provided by a network 
provider on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture repairs on March 3, 2022. 
 
You asked the Plan to pay for denture repairs. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says according to the EOC, there is no coverage for any 
denture repairs. 
 
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 denture 
repairs on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided by a network 
provider on January 13, 2022. 
 
You asked the Plan to pay for the partial upper denture (D5213). You say that the dentures are medically 
necessary. You say you had loose crowns which caused bacteria into the sinus cavity. The Plan denied your 
request. The Plan says the service was not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial upper denture (D5213) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
partial upper denture (D5213) provided by a network provider on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on February 17, 2022. 
 
You asked the Plan to pay for a dental consultation. You say that you were not aware at the time of service that 
this payment would not be covered for the D9310 consultation diagnostic service. The Plan denied your 
request. The Plan says this service is not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
consultation (D9310) provided on February 17, 2022.