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

 
We decided that the Plan does not have to issue reimbursement for the resin-based composite-two surfaces 
posterior (D2392) and the intraoral-periapical-first radiographic image (D0220) provided on August 30, 2021. 
 
You asked the Plan to issue reimbursement for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the services provided 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 dental benefit was exhausted on date of service July 27, 2021. Specifically, you previously received 
dental services on May 26, 2021 and July 27, 2021, which were paid for by the Plan in the amount of $750.  
 The Plan contract states that the Plan pays up to $750 every year for non-Medicare covered preventive dental 
services and non-Medicare covered comprehensive dental services combined. As the Plan has issued 
reimbursement previously at the maximum coverage of $750, the dental benefit has been exhausted. Therefore, 
we decided that the Plan does not have to issue reimbursement for the resin-based composite-two surfaces 
posterior (D2392) and the intraoral-periapical-first radiographic image (D0220) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth #30 provided on March 3, 2022. 
 
You asked the Plan to pay for the crown. You say that your teeth were broken, one of them had decay, and 
needed to be fixed. The Plan denied your request. The Plan says your dental allowance for the requested 
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 dental allowance for the requested service was exhausted on date of service March 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth #30 provided on 
March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two restorative procedures (D2999 x2), two applications 
of desensitizing resin (D9911 x2), and two indirect pulp caps (D3120 x2) 
 
You asked the Plan to pre-approve the restorative procedures, applications of desensitizing resin, and indirect 
pulp caps. You say that you need your bridgework to be redone. The Plan denied your request. The Plan says 
these services are purely dental in nature, and cannot be covered under your medical plan. The Plan also says 
that you are over the age limit for the indirect pulp caps to be covered. 
 
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 unspecified restorative procedures 
and applications of desensitizing resin are not among those covered under this benefit. The contract says that 
indirect pulp cap (D3120) is only covered for enrollees between the ages of 0 and 20 years old. The record 
shows that you exceed this age limit. Therefore, we decided that the Plan does not have to pre-approve two 
restorative procedures (D2999 x2), two applications of desensitizing resin (D9911 x2), and two indirect pulp 
caps (D3120 x2)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided May 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that your plan covers out-of-
network benefits. The Plan denied your request. The Plan says an exception has been made to process your 
claim as in-network, however 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 the same date of service, May 14, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230) provided May 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), a resin-based composite filling on 
tooth #11 (D2332), and pulp cap (D3120). 
 
You asked the Plan to pre-approve a filling, a crown, and pulp cap. You say that the provider should have been 
taking care of these dental issues without charging you out-of-pocket while you are under their care. The Plan 
denied your request. The Plan says that your benefit for fillings and crowns has already been exhausted. The 
Plan also says that a pulp cap 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, a pulp cap is not among those covered 
under this benefit. The record shows your benefit for resin-based composite fillings was exhausted on date of 
service April 14, 2022. The record also shows your benefit for crowns was exhausted during the processing of 
this authorization request. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), a 
resin-based composite filling on tooth #11 (D2332), and pulp cap (D3120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards for a wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The requested side guards are to equip a wheelchair for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve side guards for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on March 22, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that wearing an occlusal guard at night allows you to 
avoid damage which can cost thousands of dollars to fix. You also say that you would like the Plan's denial to 
be reconsidered. 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 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 
occlusal guard (D9944) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to start seeing a new dentist. 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 9, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at the time of an implant placement on 
tooth #20, 22, 24, and 26 (D6104). 
 
You asked the Plan to pre-approve bone grafts. You say that you would like coverage for these services to be 
reconsidered. The Plan denied your request. The Plan says a bone graft at the time of an implant placement 
(D6104) 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 a 
bone graft at the time of an implant placement on tooth #20, 22, 24, and 26 (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on May 31, 2022. 
 
You asked the Plan to pay for full mouth debridement (D4355). You say that you were told at the time of 
service that a typical cleaning could not be done. You say that you think this is not fair. The Plan denied your 
request. The Plan says this service is not covered under your 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 full mouth debridement 
(D4355) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for full mouth debridement (D4355) provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair provided on March 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lift chair (A9270). You say that your physician sent a letter to show medical 
necessity. The Plan denied your request. The Plan says the lift chair is not a covered service, was obtained out-
of-network, and was not approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lift chair provided on March 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300) for a power wheelchair.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. Your medical and rehabilitation needs do not require the 
intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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 pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you dropped your dentures in the toilet. 
You say that without them you cannot eat. 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 June 21, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown on tooth #2 (D6063) and 
an implant supported crown on tooth #2 (D6065). 
 
You asked the Plan to pre-approve the crowns. You say that you were under the impression that these services 
would be covered. The Plan denied your request. The Plan says an abutment supported crown (D6063) and an 
implant supported crown (D6065) 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 
abutment supported crown on tooth #2 (D6063) and an implant supported crown on tooth #2 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy (D4212) and a surgical procedure for 
isolation of tooth with rubber dam (D3910) provided by a participating provider. 
 
You asked the Plan to pre-approve gingivectomy and a surgical procedure for isolation of tooth with rubber 
dam. You say that these services are medically necessary. The Plan denied your request. The Plan says the 
requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingivectomy (D4212) and a surgical procedure for isolation of tooth with rubber dam (D3910) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214) provided by a 
contracted provider. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's denture is ill-fitting, and he 
cannot wear it. 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 November 5, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214) 
provided by a contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on April 20, 2022. 
 
You asked the Plan to pay for local anesthesia. You say that you do not understand why the service is not 
covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local 
anesthesia (D9215) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic - porcelain fused to high noble metal (D6240), 
core buildup, including any pins when required (D2950), and retainer crowns - porcelain fused to high noble 
metal (D6750) provided January 27, 2022. 
 
You asked the Plan to pay for the pontic, core buildup and retainer crowns. You say that you believed that 
since the services were medically necessary, they would be covered. 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 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 
pontic - porcelain fused to high noble metal (D6240), core buildup, including any pins when required (D2950), and 
retainer crowns - porcelain fused to high noble metal (D6750) provided January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care; first 30-74 minutes (99291) provided on 
January 24, 2022. 
 
You asked the Plan to pay for the critical care. You say that the code at issue is supported. The Plan denied 
your request. The Plan says the billed procedure code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the provided documentation 
does not support that the critical care services that took place lasted at least 30 minutes. Based on this 
information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care; first 30-74 minutes (99291) provided on January 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and two additional 
intraoral periapical x-rays (D0230 x2) provided on May 19, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were charged for these x-rays 
after you told the provider you did not want any services rendered that your insurance did not cover. The Plan 
denied your request. The Plan says these services are not covered under your 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. The only type of intraoral x-rays covered under the Plan are complete 
intraoral x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray 
(D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on May 19, 2022.