Persius/hicric huggingface dataset:
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 had a fall while in the hospital and has since
been bedbound. You say you need rehabilitation to get stronger and be safe at home. The Plan denied your
request. The Plan says the 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 you continue to have a need for skilled therapy with ongoing safety concerns and a
potential for functional improvement however, the documentation doesn't support that you would meet criteria
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician
with at least three visits weekly to regain or maintain her functional status.

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 issue reimbursement for the custom fabricated abutmentincludes 
placement (D6057) and the abutment supported porcelain fused to metal crown (high noble metal) (D6059) 
provided on May 16, 2022. 
 
You asked the Plan to issue reimbursement for these dental items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue 
are not covered under your contractual policy. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
custom fabricated abutmentincludes placement (D6057) and the abutment supported porcelain fused to metal 
crown (high noble metal) (D6059) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you need new 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 partial dentures was exhausted on date of service September 9, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial 
lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 2. 
 
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 extraction 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 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 
surgical extraction (D7210) for tooth # 2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiographic images (D0230) and an application of 
fluoride varnish (D1206) provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you would be charged for the 
dental services. The Plan denied your request. The Plan says your benefit for the radiographic images has 
already been exhausted and the denial of payment for the application of fluoride varnish is correct, because it is 
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 application of fluoride varnish is 
not among those covered under this benefit. The record also shows your benefit for the radiographic images was 
exhausted on date of service of May 31, 2022. Therefore, we decided that the Plan does not have to pay for the 
radiographic images (D0230) and an application of fluoride varnish (D1206) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with surgical procedures of 
tooth #1 and #32 (D9215) and a blood glucose level test (D0412) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had two teeth pulled and would not have 
been able to withstand the pain without the anesthesia. You also say that you suffer with high blood sugar and 
if it falls too low, you pass out. The Plan denied your request. The Plan says the requested services are not 
covered under your contract with 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 local 
anesthesia in conjunction with surgical procedures of tooth #1 and #32 (D9215) and a blood glucose level test 
(D0412) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2962), bone graft at time of implant 
placement (D6104), and five scalings and debridements (D6081). 
 
You asked the Plan to pre-approve a labial veneer, bone graft, and scalings and debridements. The Plan denied 
your request. The Plan says these services are not covered under the enrollee's benefit 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 a 
labial veneer (D2962), bone graft at time of implant placement (D6104), and five scalings and debridements 
(D6081).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that you have had a sore for 
some time, and need this biopsy approved. The Plan denied your request. The Plan says this procedure is 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 an 
incisional biopsy of oral tissue (D7286).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertical shock reducing pylon feature (L5988). 
 
You asked the Plan to pre-approve a vertical shock reducing pylon feature. You say that this equipment is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the requested vertical shock reducing pylon feature is not medically 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 a vertical shock reducing pylon feature. 
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 
the vertical shock reducing pylon feature at issue in this case meets all Medicare criteria for medically 
reasonable and necessary. Provided medical records from the enrollee's treating physician make no mention of the vertical shock reducing pylon feature and do not document that the enrollee participates in any high impact 
activity that would require such a feature. The enrollee is a K2 level ambulator who uses a wheelchair at times 
and requires mobility for shopping, going to appointments and social activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vertical shock reducing pylon feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a vertical shock reducing pylon feature (L5988).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 83789-59 provided on 
February 24, 2022. 
 
You asked the Plan to pay for the laboratory services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says no separate payment 
can be made for the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services as billed have not been met. Specifically, we find that the testing described 
by the billed code is considered specimen validity testing which is not separately payable. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded 83789-59 provided on February 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retreatment of previous root canal therapy on a 
premolar (D3347) and a retreatment of previous root canal therapy on a molar (D3348). 
 
You asked the Plan to pre-approve retreatments of previous root canals. You say that these services were 
approved before the pandemic, but you were unable to get the work done. You also say that once the pandemic 
was over, your dental provider said you waited too long and needed to see an endodontist. The Plan denied 
your request. The Plan says these services are not covered under your 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 
retreatment of previous root canal therapy on a premolar (D3347) and a retreatment of previous root canal 
therapy on a molar (D3348).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), endodontic therapy on 
tooth #4 (D3320), and cone beam imaging (D0364) provided on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were given misinformation from the 
provider's office. The Plan denied your request. The Plan says your maximum dental benefit has been 
exhausted. The Plan also says that cone beam imaging (D0364) is not covered by your routine dental benefits. 
 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 this benefit includes 
coverage up to $2,000 for only the items and services listed in the Covered Routine Dental Benefits chart. You 
are responsible for any amount above the maximum dental benefit amount. 
 
The record shows your maximum dental benefit has been exhausted. You are responsible for any amount above 
the benefit limit. An oral evaluation and endodontic therapy fall within the Dental Services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, cone beam imaging is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140), endodontic therapy on tooth #4 (D3320), and cone beam imaging (D0364) provided on 
March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this dental visit was a priority and essential 
process for receiving basic services included in your benefits. You also say that you signed a treatment case 
with the provider which shows you would owe nothing for the services provided. The Plan denied your request. 
The Plan says your benefits for the requested services have 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 benefits for the requested services were exhausted on date of service September 9, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate upper denture (D5130). 
 
You asked the Plan to pre-approve an immediate denture. You say that all of your top teeth will be extracted, 
so it is necessary for you to have an immediate denture while awaiting your more permanent upper denture. 
The Plan denied your request. The Plan says your benefit for the requested item would be exceeded with this 
request, as a complete upper denture (D5110) was also requested and has been pre-approved. 
 
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 one denture 
per arch every 60 months. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that your original request includes a complete upper denture (D5110) which has already been pre-
approved by the Plan. A second denture for the upper jaw at the same time would exceed the frequency 
limitations of your benefit. Therefore, we decided that the Plan does not have to pre-approve an immediate 
upper denture (D5130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions, therapy procedure using exercise to develop strength, and supervised physical medicine and 
rehabilitation modalities provided on May 2, 2022. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions, therapy 
procedure using exercise to develop strength, and supervised physical medicine and rehabilitation modalities. 
The Plan denied your request. The Plan says that the Plan only covers manual manipulation of the spine to 
correct subluxation. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions, therapy 
procedure using exercise to develop strength, and supervised physical medicine and rehabilitation modalities 
provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were assured that you would not be billed 
for this. 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 March 18, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a 
participating provider on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are no longer able to stand safely and pivot 
in the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (81238, 
81286, 81410, 81411, 81439 and 81479) provided January 26, 2021. 
 You asked the Plan to pay for cardiac risk assessment genetic screening testing. You say that the testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for cardiac risk assessment genetic screening testing (81238, 81286, 81410, 
81411, 81439 and 81479) provided January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation in the upper and lower left quadrants 
(D4921), periodontal scaling in the lower left quadrant (D4341), and periodontal scaling on tooth #10 (D4342) 
provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the provider was contracted. 
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 gingival irrigation in the upper and lower left quadrants (D4921), periodontal scaling in the lower left 
quadrant (D4341), and periodontal scaling on tooth #10 (D4342) provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 21, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the code is not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing services provided on March 21, 2022.