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

 
We decided that the Plan does not have to pay for an additional periapical radiographic image of tooth #1 
(D0230) and topical fluoride application (D1208) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were preventative, and the provider 
contacted to Plan prior to the date of service to confirm coverage of x-rays. You also say that even though the 
fluoride treatment is considered a preventative service, you were aware that the service would likely not be 
covered. You say you are not contesting this service. The Plan denied your request. The Plan says your benefit 
for the x-ray has already been exhausted. The Plan also says that the topical fluoride is not a covered benefit 
and was denied correctly. 
 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 dental x-ray was exhausted on date of service June 28, 2022. The record shows that 
you also received a series of bitewing x-rays on the date of service, which is included in the two allowed x-rays 
per calendar year. Additionally, the fluoride treatment is not among those services covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for an additional periapical radiographic image of 
tooth #1 (D0230), and topical fluoride application (D1208) provided on June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
March 20, 2022, to March 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital care was medically 
necessary. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary 
per MCG care guidelines, 25th Edition - General Admission Criteria GRG: CG-GAC (ISC GRG). 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care provided from 
March 20, 2022, to March 21, 2022. Our reviewer says that the documentation does not support that the criteria 
for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the 
time of inpatient admission the admitting physician reasonably expected that your necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care provided from March 20, 2022, to March 21, 2022. 
have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital 
care provided from March 20, 2022, to March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 pay for the dental 
services on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4266), a bone replacement graft for 
ridge preservation (D7953), and implant placement (D6010) of tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that you understand the services are not 
covered, but you want to know if the services can be covered anyway. The Plan denied your request. The Plan 
says the claim was processed correctly. The contract clearly indicates that the requested services 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 not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gum 
surgery (D4266), a bone replacement graft for ridge preservation (D7953), and implant placement (D6010) of 
tooth #4.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an HHA, five (5) hours a day, seven (7) days a week. 
 
You asked the Plan to pre-approve the HHA services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the HHA services. Our physician 
reviewer found the enrollee is medically stable without any recent hospitalizations or medical complications. 
The approved weekly hours of HHA services allow for appropriate support and care. The documentation does 
not support that the additional hours are needed to provide adequate support for the enrollee.  
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 HHA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an HHA, five (5) hours a day, seven (7) days a week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services on April 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental services on April 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 22, 2022. 
 
You asked the Plan to pay for the services. You say that you feel this claim was denied in error. 
 The Plan denied your request. The Plan says the information provided indicates transportation other than an 
ambulance could have been utilized without endangering the enrollee's health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable and necessary. Our physician reviewer found that 
transportation via ambulance to and from the enrollees dialysis session on 1/22/2022 was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. The enrollee was not bedbound, as evidenced by his ability to 
sit in his wheelchair. Transportation could have been provided by other means (stretcher van, wheelchair van, 
private car, taxi) without endangering the enrollees condition. A prudent layperson would not believe that 
immediate medical attention was required for someone attending a scheduled appointment. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided 
on January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement, tooth #'s 10 
and 12 (D6104). 
 
You asked the Plan to pre-approve the bone graft at time of implant placement, tooth #10 and 12 (D6104). You 
say to please review and reconsider coverage. 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 pre-approve a 
bone graft at time of implant placement, tooth #'s 10 and 12 (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plaque removal, bite-wing x-rays, and a comprehensive oral 
evaluation (D0274, D0150, D1110) provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 requested items or services 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 plaque removal, bite-wing x-rays, and a comprehensive oral evaluation (D0274, D0150, D1110) 
provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820). 
 
You asked the Plan to pre-approve the interim partial denture (including retentive/clasping materials, rests, and 
teeth), maxillary (D5820). 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 pre-approve an 
interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the enrollee has reached the rental cap on this item. 
 
The Plan must follow Medicare rules. Medicare rules say that the rental period for a hospital bed is 13 months. 
 
We looked at the file and Medicare rules. The rental period for a hospital bed is 13 months. This means that 
once the enrollee has had the hospital rented for 13 months, no additional payments can be made on this item. 
Review of the file shows that the enrollee originally received the hospital bed in October 2021. This means the 
13 months ends October 2022. Based on this information, we decided that Medicare rules for coverage of a hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a hospital 
bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), pontic, porcelain/ceramic (D6245), and retainer crown, porcelain/ceramic (D6740). 
 
You asked the Plan to pre-approve dental services. You say that you hope this will be approved so you can get 
your bridge. The Plan denied your request. The Plan says only those items and services specifically listed in 
your Plan contract. 
 
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. Pontic, porcelain/ceramic 
(D6245), and retainer crown, porcelain/ceramic (D6740) are not covered under the Plans dental benefits. Core 
buildup, including any pins when required (D2950) is a covered benefit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested pontic, porcelain/ceramic 
(D6245), and retainer crown, porcelain/ceramic (D6740) are not among those covered under this benefit. While 
D2950 is a covered benefit, this service is performed to build up the coronal structure when there is insufficient 
retention for a separate extra coronal restorative procedure and cannot be approved without a separate covered 
extra coronal restorative procedure. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950), pontic, porcelain/ceramic (D6245), and retainer crown, 
porcelain/ceramic (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening  hard tissue (D4249). 
 
You asked the Plan to pre-approve the clinical crown lengthening  hard tissue (D4249). 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 pre-approve 
clinical crown lengthening  hard tissue (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) and the guided tissue 
regeneration (D4266) for tooth #11 provided on May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal the denied dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the bone replacement graft and the guided tissue regeneration are not covered by the 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 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 bone 
replacement graft (D4263) and the guided tissue regeneration (D4266) for tooth #11 provided on May 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the services requested 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 pre-approve 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal and crown (D3310, D2954) provided on 
February 23, 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 a root 
canal and crown (D3310, D2954) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in all four quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that this service is medically necessary. The 
Plan denied your request. The Plan says that there is no evidence of significant bone loss. 
 
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 periodontal 
scaling when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve periodontal scaling. Our reviewer says 
that the coverage criteria has been met. Our physician reviewer found that as there are four or more involved 
teeth per quadrant, with loss of bone and abnormal pocket readings, the requested treatment would be 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling have been met. Therefore, we decided that the Plan has to 
pre-approve periodontal scaling and root planing in all four quadrants (D4341).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5214) 
 
You asked the Plan to pre-approve the dental service. You say that you returned the last pair of dentures and 
need new ones. 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 item or service was exhausted on the date of service of May 25, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial denture (D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant (D6111). 
 
You asked the Plan to pre-approve the dental service. You say that your dentist advised you that this dental 
service would help you. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because implants are not covered by the 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of a gum lesion (41822). 
 
You asked the Plan to pre-approve the excision of a gum lesion (41822). You say that you were told you would 
not have to pay a dime and you would be contacted for the procedure to be performed. You say that you were 
not advised of the denial of authorization. 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 pre-approve an 
excision of a gum lesion (41822).