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

 
We decided that the Plan has to pre-approve a retainer crown on tooth #19 for a fixed bridge. 
 
You asked the Plan to pre-approve a retainer crown. You say this bridge is necessary, and you need all three 
parts approved. The Plan denied your request. The Plan says that the service necessary for tooth #19 would be 
best reported as an abutment supported retainer crown (D6069), as this tooth is an implant rather than a natural 
tooth. This means that this service cannot be covered, as dental implants are not covered by your dental 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. In addition, Medicare rules say 
that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. 
 
The Plan pre-approved a pontic (D6240) for tooth #20 and a retainer crown (D6750) for tooth #21. The Plan 
denied the requested retainer crown for tooth #19, stating that the hypothetical procedure code provided is 
incorrect for the service which would be necessary, as tooth #19 is an implanted tooth rather than a natural one. 
The Plan then argues that this specific service, as it would be provided for an implanted tooth, is not covered by 
the Plans dental benefit. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the dental packet provided lists retainer crowns as a covered service 
and states only that dental implants are not covered. Although an abutment supported retainer crown may be 
related to an implant, it is not the same as a dental implant. It is, however, a type of retainer crown. The 
information provided by the Plan does not include a copy of your contract, nor does it include any further 
information clarifying non-covered dental services. In addition, because the other two components of this fixed 
bridge have been pre-approved, we can presume this service is reasonable and necessary, and the retainer 
crown is a necessary component to complete this otherwise approved treatment. The Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pre-approve a retainer crown on tooth #19 
for a fixed bridge.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electronic connection 
between wheelchair controller and 2 or more power seating system motors (E2311) 
harness for upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee meets all requirements 
laid out in the LCD and Policy Articles. The Plan denied your request. The Plan says the upgraded electronics 
are 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee does not need to control any power options through a joystick. The enrollee's 
upper extremity strength and function support that the enrollee can control any power options through their 
own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electronic connection between wheelchair 
controller and 2 or more power seating system motors (E2311) harness for upgrade to expandable controller (E2313).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional home health aide visits and three (3) 
additional occupational therapy visits. 
 You asked the Plan to pre-approve additional home health aide visits and additional occupational therapy visits. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health aide visits and 
additional occupational therapy visits. Our reviewer says that the documentation does not support that the 
requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has 
recurrent falls. The enrollee required contact guard assistance for transfers. While the enrollee requires 
assistance and supervision, the records do not show that these services must be provided by a skilled therapist 
or certified aide. The enrollee appears to be functioning at a level such that activities of daily living assistance 
can be provided by a layperson. Therefore, the enrollee does not require services beyond what the Plan has 
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 home health aide visits and additional occupational therapy visits 
have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional home 
health aide visits and three (3) additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue (D7286) and alveolopasty 
(D7310) provided March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the biopsy should be covered. The Plan 
denied your request. The Plan says an incisional biopsy of oral tissue (D7286) and alveolopasty (D7310) are 
not covered by 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 an 
incisional biopsy of oral tissue (D7286) and alveolopasty (D7310) provided March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and surgical 
extractions to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and surgical extractions. You say that 
you have nine teeth that need to be removed, including a lump on the roof of your mouth. The Plan denied your 
request. The Plan says the supplemental dental services benefit of your contract only provides coverage for 
dental services when they are performed by a participating general dentist. The Plan also says 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 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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation and surgical extractions 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 the intraoral-
complete series of radiographic images (D0210) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided in this case was exhausted on date of service March 4, 2021. The 
Plan contract states that a comprehensive oral evaluation and an intraoral-complete series of radiographic 
images are covered once every three plan years.  
 You previously received these services on March 4, 2021; which have been paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230 x 2), and unspecified preventive service (D1999 x 2) provided on May 3, 2022, by the out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you needed your veneer replaced. You say that 
the x-rays are a covered service. You also say that these should be paid. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150), periapical x-rays (D0220, D0230 x 2), and unspecified 
preventive service (D1999 x 2) provided on May 3, 2022, by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen tanks for use with a stationary 
concentrator. 
 
You asked the Plan to pre-approve the portable oxygen system. You say that the enrollee requires oxygen 
supplementation during sleep based on the recent overnight oxygen measurements. The Plan denied your 
request. The Plan says it is confirmed that the enrollee does require oxygen during sleep, and a stationary 
oxygen concentrator was approved. However, coverage cannot be approved for a portable system for use only 
during sleep. 
 The Plan must follow Medicare rules. Medicare rules say that oxygen supplementation may be covered for use 
during sleep when certain criteria are met; however, portable oxygen would not be covered in this situation.  
 
We looked at the file and Medicare rules. The file shows that oxygen is only to be used during sleep. Based on 
this information, we decided that Medicare rules for coverage of the portable oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve portable oxygen tanks for use with a 
stationary concentrator.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that you have never received a full upper denture 
despite your previous denture being billed that way. The Plan denied your request. The Plan says that partial 
denture cannot be approved after a complete denture for the same arch has been paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file indicates that you have teeth remaining in the top arch. 
Therefore, we decided that the Plan has to pre-approve a partial upper denture (D5213).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from March 12, 2022, to March 16, 2022.

You asked the Plan to pay for the inpatient psychiatric hospitalization provided from March 12, 2022, to March 16, 2022. You say that this was the medically appropriate level of care for the enrollee. The Plan denied your request. The Plan says this request is not medically necessary because the records received show as of March 11, 2022, the enrollee was no longer in need of inpatient level of care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 the inpatient psychiatric hospitalization. Our reviewer says that the enrollee did not meet the Medicare criteria for continued inpatient psychiatric care. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Our reviewer also found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 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 inpatient psychiatric hospitalization have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from March 12, 2022, to March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete mandibular denture (indirect) (D5751) 
and limited oral evaluation - problem focused (D0140) provided April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary, and you cannot 
afford the cost. The Plan denied your request. The Plan says you have exceeded the frequency limit for the 
denture reline. The limited oral exam 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, certain limitations apply. The record 
shows your benefit for the complete denture reline was exhausted on the same date of service, April 6, 2022. 
The limited oral exam is not included under your benefits.  Therefore, we decided that the Plan does not have 
to pay for the reline complete mandibular denture (indirect) (D5751) and limited oral evaluation - problem 
focused (D0140) provided April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the power seat elevation 
system is necessary. The Plan denied your request. The Plan says the item is not covered by Medicare or the 
health plan. 
 
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 pre-approve the power seat elevation system (CPT code E2300).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of a magnetic resonance imaging (MRI) 
scan of the lumbar spine (72148) provided on May 19, 2021. 
 
You asked the Plan to pay for an additional unit of a spinal MRI scan. You say that you have provided 
documentation to support the services billed. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 72148 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 72148. Based on this information, we decided that Medicare rules for coverage of 
an additional unit of a spinal MRI scan have not been met. Therefore, we decided that the Plan does not have 
to pay for an additional unit of a magnetic resonanceimaging (MRI) scan of the lumbar spine (72148) 
provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on 
February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 subsequent nursing 
facility care services provided on February 10, 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 a problem focused oral evaluation (code D0140) and 
intraoral-periapical first radiographic image (code D0220) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were an emergency, and you 
should not have to pay. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services were both exhausted on date of service March 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a problem focused oral evaluation (code D0140) 
and intraoral-periapical first radiographic image (code D0220) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two endosteal implants (D6010 x2) and two bone grafts 
at time of implant placement (D6104 x2) provided on November 16, 2021. 
 
You asked the Plan to pay for the endosteal implants and bone grafts. You say that you would like these 
services to be covered under the enrollee's medical insurance, and not dental, because their injuries were caused 
by an automobile accident. The Plan denied your request. The Plan says the denial of additional reimbursement 
for dental services under the medical benefit was appropriate given the benefit exhaustion. 
 
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, which 
are dental in nature, are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the two endosteal implants (D6010 x2) and two bone grafts at time of implant placement 
(D6104 x2) provided on November 16, 2021.