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

 
We decided that the Plan does not have to issue reimbursement for the comprehensive oral exam (D0150) and 
the intraoral-complete series of radiographic images (D0210) provided on December 23, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exceeded the allowable benefit for these services. 
 
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.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, a comprehensive oral exam and an intraoral 
complete series of radiographic images are covered once every three years. You previously received these 
services on November 12, 2021; therefore, you have exceeded the allowable benefit for these services.  
Therefore, we decided that the Plan does not have to issue reimbursement for the comprehensive oral exam 
(D0150) and the intraoral-complete series of radiographic images (D0210) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of tooth #19 (D7140) to be provided by 
an oral surgeon. 
 
You asked the Plan to pre-approve the tooth extraction. You say that you were referred to see an oral surgeon 
for this procedure. You say you need to have the tooth pulled because it is broken and causing you pain. You 
also say you have been taking ibuprofen and Tylenol for pain and swelling. You are afraid you could get an 
abscess. The Plan denied your request. The Plan says the denial of authorization is correct. The supplemental 
dental benefits described in your contract with the Plan only provide coverage of such services performed by a 
participating general dentist. The Plan says that dental services performed by an oral surgeon 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 Plan's coverage rules apply in this case. The Plan covers up to one 
extraction each year, but the procedure must be performed by an in-network general dentist. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You asked for authorization of an extraction 
performed by an oral surgeon. Dental services are not covered when provided by oral surgeons, periodontists, 
endodontists, other dental specialists, or out-of-network dental providers.  While your requested provider 
is in-network, the Plan does not cover this service because the provider is an oral surgeon. Therefore, 
we decided that the Plan does not have to pre-approve the extraction of tooth #19 (D7140) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 2) provided 
on January 17, 2022, periodontal scaling and root planing (D4341 x 2) and a crown on tooth #31 (D2740) 
provided on February 7, 2022, and a crown on tooth #31 provided on February 18, 2022. 
 
You asked the Plan to pay for periodontal scaling and crowns. You say that these services should be covered. 
The Plan denied your request. The Plan says periodontal scaling and root planing (D4341) and crowns (D2740) 
are not covered by your preventive 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 
periodontal scaling and root planing (D4341 x 2) provided on January 17, 2022, periodontal scaling and root 
planing (D4341 x 2) and a crown on tooth #31 (D2740) provided on February 7, 2022, and a crown on tooth 
#31 provided on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 23, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable benefit for 
this 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.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract says that a limited oral evaluation is 
covered once per plan year. You received this service previously on March 17, 2022. Therefore, you have 
exceeded the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on March 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nineteen (19) 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 the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist beyond what was approved. You should be able to 
transition safely and effectively to a home exercise program with the already approved therapy. 
 
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 nineteen (19) additional physical therapy (PT) visits (97110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that you would like to increase Ozempic. The Plan 
denied your request. The Plan says Ozempic is on the self-administered drug list and is excluded from coverage 
under Part B. 
 
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 Ozempic.  
 
Benefits for Ozempic 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 waive the coinsurance for complete mandibular dentures (D5120) 
and complete maxillary dentures (D5110) provided on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for dentures. You say that the Plan will pay to $3,000. 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 70% 
coinsurance for out-of-network. The contract also says there is a $50 deductible for basic and major dental 
services.
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,135, for the complete mandibular and maxillary dentures received on January 31, 2022. The dental 
deductible was not met at the time of service; therefore, $50 was applied to satisfy the deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $50 dental deductible which applies 
to basic and major dental services. This cost sharing is a contractual obligation that had not been met at the 
time the complete mandibular dentures were received on January 31, 2022.  
 
The allowed amount remaining for your complete mandibular dentures after you paid your dental deductible is 
$750 ($800 original allowed amount - $50 deductible paid = $750 remaining allowed amount). You have been 
asked to pay $525, which is 70% of the remaining allowed amount for the complete mandibular dentures ($750 
remaining allowed amount x 70% coinsurance = $525). You have also been asked to pay $560, which is 70% 
coinsurance of the allowed amount for complete maxillary dentures ($800 allowed amount x 70% coinsurance 
= $560). Dentures falls within the Dental Services 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 
coinsurance for complete mandibular dentures (D5120) and complete maxillary dentures (D5110) provided on 
January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of a benign lesion (D7410). 
 
You asked the Plan to pay for an excision. You say that you disagree with the denial of these dental services. 
The Plan denied your request. The Plan says the excision of a benign lesion (D7410) 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 pay for the 
excision of a benign lesion (D7410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #22 and 27 (D6010). 
 
You asked the Plan to pre-approve implants. You say that you need to have the implants to properly secure 
your bottom dentures. The Plan denied your request. The Plan says endosteal implants (D6010) are not covered 
by the Plan's 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 
endosteal implants on tooth #22 and 27 (D6010).
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 as the enrollee will 
benefit from intensive acute rehab to return to her prior level of functioning. The Plan denied your request. The 
Plan says IRF care is not medically necessary and the enrollee's needs can be met 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 a resin-based composite filling on tooth #3 (D2393) provided 
on February 3, 2022. 
 
You asked the Plan to pay for a filling. You say that you were told you only had a $25 copayment and do not 
believe you needed the third filling. The Plan denied your request. The Plan says this service is covered by the 
Plan's dental benefits; however, your benefit for two procedures per calendar year have been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers two filling 
procedures per calendar year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for two fillings 
provided on January 26, 2022; therefore, the benefit for fillings have been exhausted. Therefore, we decided 
that the Plan does not have to pay for a resin-based composite filling on tooth #3 (D2393) provided on 
February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient acupuncture services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient acupuncture services. You say that you have been in pain with 
back and leg issues for over a year. You say traveling to see a network provider would be difficult to arrange 
and cause you further pain. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 outpatient acupuncture services. We found no exception that would require the 
Plan to pre-approve outpatient acupuncture services. Therefore, we decided that the Plan does not have to pre-
approve outpatient acupuncture services to be provided by an out-of-network (OON) provider.
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and the LTACH would offer no additional services. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. 
 
 
 
 
 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 the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
January 19, 2022. 
 
You asked the Plan to pay for the dental extractions. You say that you were not advised your dental plan 
changed. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 32 speech therapy (ST) visits. 
 
You asked the Plan to pay for ST visits. You say that you are requesting a fast appeal. The Plan denied your 
request. The Plan says the requested services are not reasonable and necessary, and the health plan has no 
contractual obligation to cover services that are not covered by Medicare. 
 
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 pay for ST 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 it is not clear if the therapy is part of a maintenance program to maintain the 
patient's current condition or prevent further deterioration. Our physician reviewer also found that while 
continued therapy may be indicated, there should be documentation of a home program in place to augment the 
skills being addressed in therapy since the amount, frequency and duration of the requested therapy must be 
reasonable. Our physician reviewer also found that the requested therapy cannot be considered medically 
necessary given the fact that the guideline criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ST visits. have not been met. Therefore, we decided that the Plan does not have 
to pay for 32 speech therapy (ST) visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that this has been approved before and after this 
appointment you will not need to go back to see dentist for a whole year. You also say that this is an emergency 
due to your tooth being cracked off, and you need the transportation mileage extended. The Plan denied your 
request. The Plan says the destination exceeds the limits set in the subscriber agreement. The Plan also says 
that the shortest distance is 65.2 miles, which exceeds the 50-mile limit. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visit. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee needs additional physical 
therapy for pain control and functional improvement. The Plan denied your request. The Plan says the enrollee 
does not meet the coverage criteria for additional physical therapy. 
 
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 physical therapy. 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 there is no documentation that the requested therapy is generally 
accepted as specific and effective therapy for the enrollee's condition. The records do not show that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, or that the services can 
be safely and effectively performed only by a therapist or under the supervision of a therapist. Further 
utilization of a home exercise program appears appropriate at this point. The requested services are not part of a 
maintenance program or required to establish, design, and/or deliver a program to maintain the enrollee's 
current condition or prevent further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 physical therapy visit.