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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you felt it was necessary to find a different 
provider. 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 Plan's 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 date of service September 24, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) sedation (D9239, D9243). 
 
You asked the Plan to pre-approve IV sedation. You say that this service is necessary to have your teeth 
extracted. The Plan denied your request. The Plan says intravenous sedation (D9239, D9243) is 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 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 pre-approve 
intravenous (IV) sedation (D9239, D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve operating room services (D9500) and an office visit for 
observation (D9430). 
 
You asked the Plan to pre-approve operating room services and an office visit. You say that these services are 
medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit 
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 pre-approve 
operating room services (D9500) and an office visit for observation (D9430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim maxillary denture (D5810) and an interim 
mandibular denture (D5811). 
 
You asked the Plan to pre-approve interim dentures. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an interim maxillary denture (D5810) and an interim 
mandibular denture (D5811) 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 pre-approve an 
interim maxillary denture (D5810) and an interim mandibular denture (D5811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images provided 
on April 27, 2022. 
 
You asked the Plan to pay for intraoral - complete series of radiographic images. You say that the provider 
should know what is covered, therefore you should not be responsible for the charge. The Plan denied your 
request. The Plan says the service is covered but limitations apply. 
 
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. Preventive dental services 
benefit includes a complete intraoral series and panoramic film are each limited to once every 60 months. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered intraoral  
complete series of radiographic images on June 2, 2021. You received the same service on April 27, 2022, 
which is less than the once every 60-month limitation. Therefore, we decided that the Plan does not have to pay 
for intraoral - complete series of radiographic images provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0367) provided 
on March 29, 2022. 
 
You asked the Plan to pay for the dental services. 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 cone beam CT capture and interpretation (D0367) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided April 22, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that you believe dental consultations are covered 
under your benefits. 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary denture repair (D5512) provided on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of any limitations. 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 date of service May 16, 2022. Therefore, 
we decided that the Plan does not have to pay for maxillary denture repair (D5512) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), implant 
/abutment supported removable denture  (D6111), radiographic/surgical implant index (D6190), bone graft at 
time of implant placement (D6104), interim complete denture (D5811), semi-precision abutment  placement 
(D6191), cone beam CT image capture (D0380), and semi-precision attachment  placement (D6192). 
 
You asked the Plan to pre-approve the dental services. You say that these are necessary procedures. The Plan 
denied your request. The Plan says these services are not a covered benefit 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 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 
surgical placement of implant body (D6010), implant /abutment supported removable denture  (D6111), 
radiographic/surgical implant index (D6190), bone graft at time of implant placement (D6104), interim 
complete denture (D5811), semi-precision abutment  placement (D6191), cone beam CT image capture 
(D0380), and semi-precision attachment  placement (D6192).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital level of care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
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 supports that the criteria for inpatient care are met. Our physician reviewer found 
the enrollee is scheduled for lumbar decompression fusion after failing conservative therapy. The records 
support a reasonable expectation that the enrollee will require at least two midnights of inpatient care for the 
planned surgery. The inpatient level of care is reasonable and medically necessary. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital level of care.  
 
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 pay for a limited oral evaluation (D0140) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that no dentist would replace a broken crown 
without doing an exam first. You say that you feel the plan should pay for mandatory exams. 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 Plan's 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 date of service February 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete x-ray series (D0210) provided on April 15, 2022. 
 
You asked the Plan to pay for x-rays. You say that the x-rays should be covered. The Plan denied your request. 
The Plan says a complete x-ray series (D0210) is 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 a 
complete x-ray series (D0210) provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the office visit (99214), Tetanus vaccine 
(90715), and administration (90471) provided on May 4, 2022. 
 
You asked the Plan to pay the full amount for the vaccine and administration. You say that this was an annual 
physical exam. You say that the services should have been covered. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that vaccinations or inoculations are excluded as 
immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or 
condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the vaccine and administration have not been met. Specifically, the file does not indicate that you 
have a qualifying diagnosis for the Tetanus vaccine. Since the vaccine is not covered, the administration is not 
covered either. Therefore, we decided that the Plan does not have to pay the full amount for the office visit 
(99214), Tetanus vaccine (90715), and administration (90471) provided on May 4, 2022.  
 
Benefits for the vaccine and administration 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 pre-approve complete denture - upper (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and unable to eat on the left 
side due to poor dentures. 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 date of service October 14, 2019. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - upper (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4). 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is medically necessary. The 
Plan denied your request. The Plan says gingival irrigation (D4921) is 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 pre-approve 
gingival irrigation (D4921 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided on November 20, 2021.

You asked the Plan to pay for the services provided. You say that reconsideration for medical necessity is being requested. The Plan denied your request. The Plan says the rules for reimbursement have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We find that CPT code G0463 was billed with diagnosis code T50.X95A - adverse effect of other vaccines and biological substances, initial encounter. The claim information does not show that the appropriate code for the nature of the adverse effect was billed.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided on November 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital visits provided on January 25, 2022, and January 26, 2022.

You asked the Plan to waive the copayments for outpatient hospital visits. You say that you feel you should not be charged a copayment for an outpatient hospital visit. The Plan denied your request. The Plan says the copayment applied is correct.

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 $10 copayment for all other Medicare-covered outpatient hospital services. 

You have been asked to pay $10 copayment for each outpatient hospital visit, resulting in a total amount of $20. An outpatient hospital visit falls within the Outpatient Hospital 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 copayments for outpatient hospital visits provided on January 25, 2022, and January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921) X 4. 
 
You asked the Plan to pre-approve gingival irrigation. The Plan denied your request. The Plan says the 
requested service is not a covered benefit under the enrollee's dental 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 
gingival irrigation  per quadrant (D4921) X 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) and re-treatment of a previous 
root canal on tooth #24 (D3346) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for intraoral x-rays has already been exhausted. The 
Plan also says that re-treatment of a previous root canal (D3346) is not covered by your supplemental 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, certain limitations apply. The record 
shows your benefit for an intraoral x-ray was exhausted on date of service May 4, 2022. Re-treatment of a 
previous root canal (D3346) is not a covered service under this benefit. Therefore, we decided that the Plan 
does not have to pay for an intraoral x-ray (D0220) and re-treatment of a previous root canal on tooth #24 
(D3346) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
extractions (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and extractions. You say that you have a heart condition and 
cannot have these services done by a general dentist. The Plan denied your request. The Plan says that the 
requested items and services are covered but only when received by a participating general dentist. 
 
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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) and extractions (D7210) provided by an 
oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met. Our physician 
reviewer found the enrollee is scheduled for revision of hip arthroplasty. The submitted records do not indicate 
that the treating physician has a reasonable expectation of a length of stay spanning two or more midnights, 
taking into account complex medical factors. The inpatient level of care is not reasonable or medically 
necessary. 
 
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 pre-approve the acute inpatient hospital level of care.