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

 
We decided that the Plan does not have to pay for the dental services on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe that the maximum hadn't been 
reached yet. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has 
exceeded limits set in the subscriber agreement (Member had already reached their $500 Annual Max in prior 
dental visits). 
 
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 previously exhausted. Therefore, we decided that the 
Plan does not have to pay for the dental services on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided June 21, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to a find a new in-network 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 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 April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
June 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the medical records support payment. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99053 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99053 billed for date of service January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are an established patient. 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 dental services provided on May 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve radiation therapy services with an out-of-network provider. You say that the 
services are medically necessary. The Plan denied your request. The Plan says enrollees must receive medical 
care/services from in-network providers. The requested radiation treatments can be provided by one of the 
Plan's participating providers. 
 
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 
radiation therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture realignment (D5750) provided 
on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for the second realignment 
because it is cheaper than getting 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 item or service was exhausted on date of service May 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a complete maxillary denture realignment (D5750) provided 
on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on May 11, 2022, to May 24, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental work 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 a limited 
oral evaluation (D0140) provided by a participating provider on May 11, 2022, to May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses, frames and related vision charges provided 
by an out-of-network (OON) provider.  
You asked the Plan to pay for the vision services. You say that you would like to be reimbursed for these 
charges as they were medically necessary to correct your vision. The Plan denied your request. The Plan says 
prior authorization was not obtained for services rendered by an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers these services when they are provided by an in-network provider. 
 
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses, frames and related vision charges provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay 
more for the extraction (D7210) provided on June 7, 2022, and June 9, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and to pay more for the extraction. 
The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered 
expense under your dental plan. The Plan also says that the extraction processed correctly 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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract clearly states that you are 
responsible for a 50% coinsurance for extractions rendered by an in-network provider. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the 
extraction (D7210) provided on June 7, 2022, and June 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs skilled therapy to continue or it 
will affect health. The Plan denied your request. The Plan says the denial of authorization for additional SNF 
care is correct, because SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 28, 2022 
to July 31 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve additional skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this provider was out-of-
network. 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 dental services provided by an out-of-network provider on May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urine mycotoxin panel testing (A9270) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve laboratory services. You say that you had a test on your lungs and 
discovered that you have mold in your lungs. The requested urine test will determine if its currently present in 
your body or previous to you moving into your residence. The Plan denied your request. The Plan says you 
must use network providers to get your medical care and services. The Plan also says that the requested test is 
not covered by Medicare or 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. Additionally, records show that these tests are not covered by 
Medicare or the Plan and are only covered as a cash out of pocket expense. Therefore, we decided that the Plan 
does not have to pre-approve a urine mycotoxin panel testing (A9270) to be provided by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 25, 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 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 January 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services received on April 11, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that 12 visits within 90 days does not meet 
your needs. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you previously received acupuncture services in 
January, February, and March of 2022. This means you have exceeded your 90-day plan benefit maximum. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services received on April 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular and maxillary adjustment (D5411 and 
D5410) and an indirect complete mandibular and maxillary realignment (D5750 and D5751), provided by a 
participating provider on February 9, 2022, to February 28, 2022. 
 
You asked the Plan to pay for a complete mandibular and maxillary adjustment and an indirect complete 
mandibular and maxillary realignment. You say that all of these services should be covered. The Plan denied 
your request. The Plan says the rendered 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 pay for a 
complete mandibular and maxillary adjustment (D5411 and D5410) and an indirect complete mandibular and 
maxillary realignment (D5750 and D5751), provided by a participating provider on February 9, 2022, to 
February 28, 2022.
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 does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a stroke and was discharged home on 9/2/22. There is ongoing weakness. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial of the dental 
services you received on June 9, 2022. 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 15, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing - four or more 
teeth per quadrant (D4341) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7240) and therapeutic 
parenteral drugs (D9612) provided by a participating provider on January 28, 2022. 
 
You asked the Plan to pay for the removal of impacted tooth and therapeutic parenteral drugs. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered 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 pay for the 
removal of impacted tooth (D7240) and therapeutic parenteral drugs (D9612) provided by a participating 
provider on January 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that your ILR needs to be replaced. The Plan denied 
your request. The Plan says that there is no documentation to support this replacement implantable loop 
recorder would change management. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. Our physician reviewer found that your condition does not meet criteria for coverage of 
these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).