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

 
We decided that the Plan does not have to pay for an oral evaluation and fluoride treatment (D0120 D1206) 
provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 7, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation and fluoride treatment (D0120 D1206) 
provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation, periapical x-rays and bitewing x-rays 
(D0120, D0220, D0230) provided on June 22, 2022 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 an oral evaluation, periapical x-rays and bitewing x-rays (D0120, D0220, D0230) provided on June 
22, 2022 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework 
with resin denture bases (D5214), and maxillary partial denture - cast metal framework with resin denture bases 
(D5213). 
 
You asked the Plan to pre-approve a mandibular partial denture - cast metal framework with resin denture 
bases (D5214), and maxillary partial denture - cast metal framework with resin denture bases (D5213). The 
Plan denied your request. The Plan says these services are not covered under the 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 
mandibular partial denture - cast metal framework with resin denture bases (D5214), and maxillary partial 
denture - cast metal framework with resin denture bases (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214) and relining a 
complete maxillary denture (D5750). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says a partial mandibular denture (D5214) and relining a complete 
maxillary denture (D5750) 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 a 
partial mandibular denture (D5214) and relining a complete maxillary denture (D5750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #14 (D2740), core build up on tooth 
#14 (D2950), a limited oral evaluation (D0140), pulp vitality test on tooth #14 (D0460), and gingival irrigation 
(D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a crown (D2740), core build up (D2950), a limited oral 
evaluation (D0140), a pulp vitality test (D0460), and gingival irrigation (D4921) 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 pre-approve a 
crown on tooth #14 (D2740), core build up on tooth #14 (D2950), a limited oral evaluation (D0140), pulp 
vitality test on tooth #14 (D0460), and gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown (D6750) for tooth number 28 and tooth number 31. 
 
You asked the Plan to pre-approve retainer crown (D6750). You say that you do not understand why this is not 
covered. The Plan denied your request. The Plan says that to approve a bridge you must be missing only one 
upper front tooth or only two lower front teeth, two lower front teeth must be next to each other, and you also 
cannot be missing any of your back teeth. The Plan also says that our dentist looked at the x-rays your dentist 
sent us and said you are missing other teeth. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to submit the correct Evidence of Coverage (EOC) and dental 
booklet. Without the correct EOC and dental booklet, we cannot make an informed decision. Therefore, we 
decided that the Plan has to pre-approve retainer crown (D6750) for tooth number 28 and tooth number 31.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the member's tooth has too little bone 
in the middle of the roots. Your tooth would need to have more bone in the middle of the roots to be allowed. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that  Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2750) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 August 8, 2020 to 
September 3, 2020. Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2750)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment  includes modification and 
placement (D6056), and implant supported porcelain/ceramic crown (D6065) for tooth #'s 3, 4, 5, 12, 13, 14, 
19, 20, 29 and 30. 
 
You asked the Plan to pre-approve a prefabricated abutment  includes modification and placement (D6056), 
and implant supported porcelain/ceramic crown (D6065) for tooth #'s 3, 4, 5, 12, 13, 14, 19, 20, 29 and 30. You 
say that you cannot eat without the crowns. You say that you are feeling a lot of pain because you have wounds 
in your mouth.  The Plan denied your request. The Plan says these services are not covered under the 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 
prefabricated abutment  includes modification and placement (D6056), and implant supported 
porcelain/ceramic crown (D6065) for tooth #'s 3, 4, 5, 12, 13, 14, 19, 20, 29 and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), core buildup (D2950), endodontic 
therapy (D3320), scaling and root planing (D4342), partial dentures (D5213 and D5214), and extractions 
(D7140) for tooth #1, #3, #8, #9, #17, #20, #23, #24, #25, #26, #30, and #32. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to appeal the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because a crown, core buildup, endodontic therapy, scaling and root planing, partial dentures, and extractions 
are 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 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 
crown (D2740), core buildup (D2950), endodontic therapy (D3320), scaling and root planing (D4342), partial 
dentures (D5213 and D5214), and extractions (D7140) for tooth #1, #3, #8, #9, #17, #20, #23, #24, #25, #26, 
#30, and #32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper overdenture (D5863) and precision 
attachments for teeth #6 and #11 (D6950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claim was processed correctly. The services you requested are not 
covered under 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 pre-approve a 
complete upper overdenture (D5863) and precision attachments for teeth #6 and #11 (D6950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5214) 
 
You asked the Plan to pre-approve the dental service. You say that you need a new partial denture because the 
old one does not fit. 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 the date of service of March 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a partial denture (D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in severe pain. The Plan 
denied your request. The Plan says the service exceeds the maximum count allowed per period. 
 
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.  
 
We looked at the file, and Medicare rules. A core buildup was last received on March 14, 2018. The requested 
procedure is only covered once every 5 plan years. Based on this information, we decided that the Plan's rules 
for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a dental core buildup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 6, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewings two x-
ray images (D0272) and posterior resin-based composite two surfaces (D2392) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you could only use in-
network providers. 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 the comprehensive oral evaluation (D0150), bitewings two x-ray images (D0272) and posterior 
resin-based composite two surfaces (D2392) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says dental services from an out-of-
network provider 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. 
 
 
 
 
 
 
 
 You are requesting 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 pre-approve the dental 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 20, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic for tooth #'s 4 and 
6 (D6740), and pontic - porcelain fused to high noble metal for tooth #5 (D6240). 
 
You asked the Plan to pre-approve the retainer crown - porcelain/ceramic tooth #'s 4 and 6 (D6740), and pontic 
- porcelain fused to high noble metal tooth #5 (D6240). . You say that you were told by member services you 
are covered for $4800 for dental work every year. You say that you had similar work done about two years ago 
and it was covered. The Plan denied your request. The Plan says this service is not covered under the 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 
retainer crown - porcelain/ceramic for tooth #'s 4 and 6 (D6740), and pontic - porcelain fused to high noble 
metal for tooth #5 (D6240).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (CPT code 33225) and removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system (33229).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation to support the medical necessity for removal of the dual-chamber pacemaker and replacement with a bi-ventricular pacemaker.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (CPT code 33225) and removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system (33229).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are severely deconditioned and need strength training and rehabilitation. You say that your level of function permits you to do physical therapy three times a day which you will not receive in a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to the IRF have not been met.

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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

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 IRF admission and services.