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

 
We decided that the Plan does not have to pay for the bone replacement graft, of a retained natural tooth 
(D4263) provided on January 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service is not payable as it was rendered 
by 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. 
 
The record shows that you received the requested dental service from an out-of-network provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the service provided in this case is not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for the bone replacement graft, of a retained natural tooth (D4263) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #15 (D2950) provided on February 
10, 2022. 
 
You asked the Plan to pay for core build up. You say that you think the dentist billed for unnecessary services. 
The Plan denied your request. The Plan says you have met your annual maximum for dental services. 
 
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 have met your annual maximum amount for dental services. Therefore, we decided that 
the Plan does not have to pay for core build up on tooth #15 (D2950) provided on February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that you missed your therapy for two weeks and now are 
in pain. The Plan denied your request. The Plan says you have reached your maximal level of function and can 
manage your balance program with a home exercise program. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent slow deterioration of the enrollee's 
condition. Our physician reviewer found additional visits are not medically necessary based on the review of 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve six physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0274), 
and periodontal maintenance (D4910) provided on February 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing the same provider for the 
last 20 years. 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 a periodic oral evaluation (D0120), bitewing x-rays (D0274), and periodontal maintenance (D4910) 
provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions of tooth #6, 15, 21, 22, 27, and 29 (D7210), 
extractions of tooth #8, 9, 23, 24, and 25 (D7140), aveoloplasty (D7310 x 4), and immediate dentures provided 
on November 12, 2021. 
 
You asked the Plan to pay for extractions, aveoloplasty, and immediate dentures. You say that these services 
are covered. The Plan denied your request. The Plan says extractions (D7210, D7140), aveoloplasty (D7310), 
and immediate dentures are 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 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 
extractions of tooth #6, 15, 21, 22, 27, and 29 (D7210), extractions of tooth #8, 9, 23, 24, and 25 (D7140), 
aveoloplasty (D7310 x 4), and immediate dentures provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the cone beam computed tomography (CT) 
capture and interpretation (D0367) provided on February 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the cone beam computed tomography (CT) capture and interpretation (D0367) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), panoramic x-ray (D0330), 
2D oral/facial x-ray (D0350), provisional splinting (D4321), tooth re-implantation (D7270), palliative 
treatment (D9110), local anesthesia (D9210), and an occlusal adjustment (D9951) provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary after an 
accidental fall. The Plan denied your request. The Plan says a limited oral evaluation (D0140), 2D oral/facial x-
ray (D0350), provisional splinting (D4321), tooth re-implantation (D7270), palliative treatment (D9110), local 
anesthesia (D9210), and an occlusal adjustment (D9951) are not covered by your supplemental dental benefits. 
The Plan also says your benefit for a panoramic x-ray (D0330) 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. A limited 
oral evaluation (D0140), 2D oral/facial x-ray (D0350), provisional splinting (D4321), tooth re-implantation 
(D7270), palliative treatment (D9110), local anesthesia (D9210), and an occlusal adjustment (D9951) are not 
covered under this benefit. The record shows your benefit for a panoramic x-ray was exhausted on date of 
service July 20, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140), panoramic x-ray (D0330), 2D oral/facial x-ray (D0350), provisional splinting (D4321), tooth re-
implantation (D7270), palliative treatment (D9110), local anesthesia (D9210), and an occlusal adjustment 
(D9951) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470), precision attachment, by report 
(D5862) and overdenture  complete mandibular (D5865) provided October 27, 2021, and November 9, 2021. 
 
You asked the Plan to pay for the diagnostic casts, precision attachment and overdentures. You say that the 
provider is listed online as in-network. The Plan denied your request. The Plan says these services are 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 
diagnostic casts (D0470), precision attachment, by report (D5862) and overdenture  complete mandibular 
(D5865) provided October 27, 2021, and November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided February 1, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that your dental benefits include 
coverage for x-rays. The Plan denied your request. The Plan says the cost for this service was applied to your 
deductible. 
 
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 the complete 
series of x-rays with 50% coinsurance after $100 deductible is met.  
 
We looked at the file and Medicare rules. The complete series of intraoral x-rays is a Class 2 Basic Service. 
The cost of this service has been applied toward your $100 deductible. This means you have been asked to pay 
the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to 
pay for the intraoral - complete series of radiographic images (D0210) provided February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of a blood sample (D7921) provided on 
January 20, 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 collection of a blood sample (D7921) 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 the 
collection of a blood sample (D7921) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0367), 2D facial images (D0350), and 
intraoral x-rays (D0230) provided on January 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not advised of the frequency 
limitations. The Plan denied your request. The Plan says cone beam imaging (D0367) and 2D facial images 
(D0350) are not covered by your supplemental dental benefits. The Plan also says that panoramic x-rays 
(D0230) are covered by the Plan's benefits; however, your benefit for one procedure per calendar year has 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, cone beam imaging (D0367) and 2D 
facial images (D0350) are not among those covered under this benefit. The record shows the paid for 
panoramic x-rays provided on January 21, 2022; therefore, the benefits for one panoramic x-ray has been exhausted. Therefore, we decided that the Plan does not have to pay for cone beam imaging (D0367), 2D facial 
images (D0350), and intraoral x-rays (D0230) provided on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on February 16, 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 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 a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on 
February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of tooth #24, 25, and 26 to existing partial 
denture (D5650) provided on March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you this service was covered. 
The Plan denied your request. The Plan says adding teeth to existing partial denture (D5650) 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 the 
addition of tooth #24, 25, and 26 to existing partial denture (D5650) provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee needs continued treatments and care that can only be given in a hospital setting. The Plan states the enrollee's continued care needs include skilled for the antivirus medicine and when they are ready to leave the hospital, the enrollee can safely receive this care in another setting, such as a skilled nursing facility (SNF) or perhaps at home with home health services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided October 12, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this service was needed as the result of an 
accident. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the limited 
oral exam when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was covered by the Plan for the date of service October 13, 2021. Based on this information, we decided that 
the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided October 12, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) admission. You say that the enrollee requests 
to go to the facility. The Plan denied your request. The Plan says for the SNF to be covered the enrollee must 
obtain care from a doctor or health care provider in the Plan. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) admission to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need to exceed the benefit to see the 
recommended specialist. You also say that you have exhausted all social resources and seeing other eye 
specialists. The Plan denied your request. The Plan says you are requesting an additional 8 miles for a total of 
58 miles. The Plan also says that your benefit only allows for 50 miles, and this request exceeds your benefit 
limit. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure (insertion of an interlaminar 
stabilization device). 
 
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex 
is experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure (insertion of an interlaminar stabilization device).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 9, 2020, 
to August 11, 2020. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of DRG 064. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 064. 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 these services. Our reviewer says that the submitted records do not support the 
billing of DRG 064. Our physician reviewer found the enrollee was brought to the emergency room with new 
symptoms of right lower extremity weakness with slurred speech and drooping. This was believed to have 
lasted an hour. Upon arrival, the enrollee had no evident neurological deficit. There is no definite history of 
prior coronary disease or myocardial infarction. He denies chest pain or shortness of breath. There is no 
documentation of palpitation, dizziness, cough or edema. A secondary diagnosis of non-ST elevated 
myocardial infarction (NSTEMI) was also documented. The records do not support the billing of DRG 064.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from August 9, 2020, to August 11, 2020.