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

 
We decided that the Plan does not have to pre-approve periapical radiographic imaging (D0220 and D0230) 
and full mouth debridement (D4355), provided by a participating provider on March 11, 2022. 
 
You asked the Plan to pre-approve dental services. 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 pre-approve 
periapical radiographic imaging (D0220 and D0230) and full mouth debridement (D4355), provided by a 
participating provider on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81405, 81406, 81162, 81201, 81212, 81321) 
provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-approved. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (81405, 81406, 81162, 81201, 81212, 81321) provided on 
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) and a prefabricated post and core 
(D2954), provided by an out-of-network provider on March 15, 2022, to April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for D0220 has already been exhausted. The Plan says that 
D2954 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 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 D0220 was exhausted on date of service March 15, 2022. D2954 is not a covered dental 
benefit. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220) and a prefabricated post and core (D2954), provided by an out-of-network provider on March 15, 2022, to April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230), a comprehensive oral 
evaluation (D0150), and bitewings (D0274), provided by an out-of-network provider on February 23, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe that all of these services should be 
covered and paid. The Plan denied your request. The Plan says services provided out-of-network are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
intraoral imaging (D0220 and D0230), a comprehensive oral evaluation (D0150), and bitewings (D0274), 
provided by an out-of-network provider on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic on tooth #3 (D6242) and a crown on tooth #2 
(D6792) provided on April 7, 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 pontics (D6242) and crowns (D6792) 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 pay for a pontic 
on tooth #3 (D6242) and a crown on tooth #2 (D6792) provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis (L1960) and addition to lower 
extremity, varus/valgus correction, plastic modification, padded/lined (L2275). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication to support ambulation support. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a chronic condition. There is no reasonable expectation for functional improvement. The criteria for coverage is not met. 
 
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 an ankle foot orthosis (L1960) and addition to lower extremity, varus/valgus correction, 
plastic modification, padded/lined (L2275).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from May 27, 2021, to 
December 7, 2021.  
 
You asked the Plan to pay for the dental services. You say that you were told that you could see any provider 
you wanted. The Plan denied your request. The Plan says the provider has opted of Medicare and is not eligible 
for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided from May 27, 2021, to December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) and 
complete series x-ray (D0210) provided on March 1, 2022. 
 
You asked the Plan to reimburse you for the dental services. You say that you got a treatment plan by your 
previous provider that you cannot afford. You say that you do not understand why you need to pay this much 
money. You also say that you cannot afford this bill. The Plan denied your request. The Plan says your benefit 
for the comprehensive oral evaluation and complete series x-ray have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation and complete series x-ray were exhausted on date of 
service January 19, 2022. Therefore, we decided that the Plan does not have to reimburse you for the 
comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) and to fix partial denture section 
(D9120) provided on September 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could see whatever 
provider you wanted. The Plan denied your request. The Plan says the provider has opted out of Medicare and 
is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) and to fix partial denture section (D9120) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
January 12, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusion analysis (D9950) provided by an out-of-network 
provider on March 3, 2022. 
 
You asked the Plan to pay for dental services. You say that this should be covered because the provider is in-
network. 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 occlusion 
analysis (D9950) provided by an out-of-network provider on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #31 (D2740) provided on January 19, 2022. 
 
You asked the Plan to pay for a crown. You say that you had a crown paid for last year and received 
reimbursement for part of that claim. The Plan denied your request. The Plan says this service is not covered by 
the Plan's benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a crown on tooth #31 (D2740) 
provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), apicoectomy 
(D3410), and sedation (D9222), provided by an out-of-network provider on March 16, 2022, to March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 Plan's 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 comprehensive oral evaluation (D0150), apicoectomy (D3410), and sedation (D9222), provided by 
an out-of-network provider on March 16, 2022, to March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays, pulp vitality test, and a root canal therapy, 
provided by an out-of-network provider on April 5, 2022. 
 
You asked the Plan to pay for periapical x-rays, pulp vitality test, and a root canal therapy. You say that this is 
the only dentist who can provide these services. 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. The Plan covers covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of periapical x-rays, pulp vitality test, and a root canal therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for periapical x-rays, pulp vitality test, and a root canal therapy, 
provided by an out-of-network provider on April 5, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Infliximab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is recommended for this enrollee. The Plan 
denied your request. The Plan says that this does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that the National 
Comprehensive Cancer Network (NCCN) guidelines for management of immunotheraoy-related toxicities 
supports the use of Infliximab for a diagnosis of stage IV poorly differentiated squamous cell carcinoma of the 
left tonsil. The enrollee is steroid-refractory, and has dysphagia from mucositis and esophagitis from 
Pembrolizumab. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Infliximab for the enrollee.  
 
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 pay for an extraction (D7210) provided by an out-of-network 
provider on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 extraction (D7210) provided by an out-of-network provider on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 1, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided February 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, the code billed has a 
professional component / technical component indicator of 8. This service is not separately payable at this 
place of service. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (85060) provided 
February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
February 10, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were rendered by an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in-network provider.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were purchased from an 
out-of-network provider. The Plan contract says that hearing aids purchased outside of the network provider are 
not covered. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5261) purchased on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the complete maxillary denture (D5110) and complete mandibular 
denture (D5120) provided on December 10, 2021. 
 
You asked the Plan to pay for the complete dentures. The Plan denied your request. The Plan says that dentures 
are not a covered benefit if the teeth are missing prior to the start of coverage unless you have had continuous 
coverage under the dental plan for 24 months. The Plan also says that you did not meet this qualification. 
 
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 did not provide any records showing if or when your teeth were 
removed prior to becoming enrolled in the Plan on January 1, 2021. Without this information, we cannot 
determine if the Plan's criteria have not been met. Therefore, we decided that the Plan has to pay for the 
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on December 10, 2021.  
 
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.