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

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5110) and a partial upper 
denture (D5211). 
 
You asked the Plan to pre-approve dentures. You say that you have been suffering a lot of pain and cannot eat. 
You say that you have lost weight and it is feeling bad. You also say that you need these services The Plan 
denied your request. The Plan says dentures are covered once every 60 months. The Plan also says that the 
frequency limit has been reached. 
 
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 and dentures are listed as covered, the 
frequency limits have been exceeded. The record shows that the Plan paid for a complete lower denture and 
partial upper denture that you received on September 21, 2020. Therefore, we decided that the Plan does not 
have to pre-approve a complete lower denture (D5110) and a partial upper denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on May 6, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the service should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Specifically, the records submitted indicate you were not enrolled in the Plan's comprehensive 
supplemental dental plan. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910), provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and complete series x-
ray (D0210) provided on August 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that 
this provider is in network. The Plan denied your request. The Plan says the provider in this case is out of 
network. The Plan also says dental service received out of network 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, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation (D0120) and complete series x-ray (D0210) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve harvest of bone for graft procedure (D7295) for tooth # 
17. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says harvest of bone for graft procedure is not listed as a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the harvest of bone for graft procedure 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve harvest of bone for graft procedure (D7295) for tooth # 17.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 microprocessor knee and ankle foot system coded as 
L5828, L5845, L5848, L5856 and L5973. 
 
You asked the Plan to pre-approve K3 microprocessor knee and ankle foot system. You say that the requested 
above knee prosthesis with a microprocessor Orion knee and elan foot (Linx system) is medically necessary 
and meets criteria. The Plan denied your request. The Plan says a K3 microprocessor knee and ankle foot 
system exceeds the enrollee's need and does not meet Medicare criteria of reasonable and 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 K3 microprocessor knee and ankle foot 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that meets the requirements for Medicare coverage for the requested K3 microprocessor knee 
and ankle foot systems. Provided records report that the enrollee is expected to still require a walking cane even 
with the requested K3 microprocessor knee and ankle foot systems. Use of a walking cane is not consistent 
with a K3 functional level and records do not support the necessity of the requested K3 microprocessor knee 
and ankle foot systems. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 microprocessor knee and ankle foot system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve K3 microprocessor knee and ankle foot system coded as 
L5828, L5845, L5848, L5856 and L5973.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a total 
shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
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. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is approved for a total shoulder arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
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 have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is receiving skilled services in his present nursing facility with no documentation of a medical need to transfer care to another facility. Records document the enrollee has had improvement in function with the therapy he has been receiving though he requires encouragement to participate. Continued care in his present facility appears indicated per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the member is not safe to discharge home at this 
time as she is very debilitated. The Plan denied your request. The Plan says the records do not show that the 
member requires daily skilled services that can only be provided on an inpatient basis. 
 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 SNF care. Our reviewer says that daily 
skilled nursing services are not necessary. Our reviewer found that there are identifiable skilled therapy needs 
but they are not required on a daily basis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive services (D1999 x 2) provided 
from February 5, 2021, to August 10, 2021. 
 
You asked the Plan to pay for the unspecified preventive services. You say that you asked the provider's office 
to verify with your plan that the services would be covered. You say that you were not informed that the 
provider was out of network. You also say that you should not have to pay for these services. The Plan denied 
your request. The Plan says unspecified preventive service is not listed as a covered 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 unspecified preventive services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive services (D1999 x 2) provided from February 5, 2021, to August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing
facility, or at home or in the assisted living facility with home health services.
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 the documentation does not support that the complexity of the enrollee's nursing,
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The documentation does not support that the enrollee requires and can tolerate at least 3
hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. The documentation does
not support that there is a reasonable expectation that this enrollee will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) and crowns (D2740) for teeth # 
2, 8 and 9. 
 
You asked the Plan to pre-approve core build up and crowns for teeth # 8 and 9. You say that the services are 
necessary. The Plan denied your request. The Plan says crowns are specifically not covered for cosmetic 
reasons or for closing gaps. The Plan also says core build up is only covered when performed together with a 
crown. 
 
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 and core build up and crowns are listed 
as covered, the Evidence of Coverage clearly states that crowns for cosmetic reasons and to close gaps are not 
covered. The provided records indicate that the crowns for teeth # 8 and 9 are for specifically for cosmetic 
reasons. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and crowns 
(D2740) for teeth # 2, 8 and 9.
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 you know you need to be worked with and you can 
recover quickly. The Plan denied your request. The Plan says IRF is not medically necessary, and your needs 
can be met at a lower level of care such as a SNF, home with home health services or home with outpatient 
therapy. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you 
have not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with 
regular physician evaluation. Your care needs can be met at a lower level of care, such as a skilled nursing 
facility. 
 
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: 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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization is denied because IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care, such as a skilled nursing 
facility (SNF). 
 
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 periodontal maintenance (D4910) provided on November 4, 2021.
You asked the Plan to pay for periodontal maintenance. You say that the services at issue are very important to you. The Plan denied your request. The Plan says the services at issue are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the 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 maintenance (D4910) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on August 12, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you were forced to go out-of-network 
because there were no providers in your area. The Plan denied your request. The Plan says the hearing aids 
were not purchased through our hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a Plan hearing network provider. 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from the 
Plans hearing network provider. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80048, 83735, 83880) 
rendered by the out-of-network (OON) provider on October 28, 2021. 
 
You asked the Plan to pay 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 the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (36415, 80048, 83735, 83880) rendered by the out-of-
network (OON) provider on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused detailed and extensive oral evaluation 
(D0160) and pulp vitality tests (D0460) provided on October 25, 2021. 
 
You asked the Plan to pay for the problem focused detailed and extensive oral evaluation and pulp vitality tests. 
You say that coverage is provided for two emergency diagnostic exams per year and two emergency treatments 
for pain per year. You also say that the Plan's payment of $27 for an emergency treatment of pain, emergency 
diagnostic exam, and x-ray, all billed at $134, does not meet the criteria expressed by the Plan. The Plan denied 
your request. The Plan says these services are not covered expenses under your dental 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 the 
problem focused detailed and extensive oral evaluation (D0160) and pulp vitality tests (D0460) provided on 
October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug, single administration 
(D9610) and the treatment of root canal obstruction; non-surgical access (D3331), provided from September 
29, 2021, through October 26, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered 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. 
 
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 
therapeutic parenteral drug, single administration (D9610) and the treatment of root canal obstruction; non-
surgical access (D3331), provided from September 29, 2021, through October 26, 2021.