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

 
We decided that the Plan does not have to pre-approve collection and application of autologous blood 
concentrate product (D7921) and a bone replacement graft (D7953). 
 
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 these services are not covered by the Plan's dental 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 
collection and application of autologous blood concentrate product (D7921) and a bone replacement graft 
(D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 endosteal implants (D6010). 
 
You asked the Plan to pre-approve 11 implants. You say that you need these implants. You also say that you 
are unable to bite down and eat. The Plan denied your request. The Plan says implants 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 11 endosteal 
implants (D6010).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 29, 2022. 
 
You asked the Plan to pre-approve SNF care after April 29, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after April 29, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found you do not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after April 29, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 29, 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 if she must go to a nursing home, she won't get the 
therapy she needs or deserves, and she is at a high risk of not getting her strength or endurance back so that she 
is able to return home. The Plan denied your request. The Plan says IRF care is not medically necessary and the 
enrollee's needs can be met at a lower level of care such as a SNF. 
 
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. The 
enrollee is medically stable and does not need PM&R physician close supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
While the enrollee may benefit from PT and OT, her rehab needs can be addressed at a low intensity alternate 
setting such as in a SNF. 
 
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 a partial maxillary denture to be provided by a participating 
provider. 
 
You asked the Plan to pay for a partial maxillary denture. You say that you would like the Plan to approve 
these services. The Plan denied your request. The Plan says the benefit limit for a partial denture 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. The Plan covers a partial 
maxillary denture when the services once every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a partial denture was provided 
on November 2, 2021. Based on this information, we decided that the Plan's rules for coverage of a partial 
maxillary denture have not been met. Therefore, we decided that the Plan does not have to pay for a partial 
maxillary denture to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental office evaluation and treatment received on 
November 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be covered under the medical benefit. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
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 dental office evaluation and 
treatment received on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that the gingival irrigation is medically 
necessary. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation  per quadrant (D4921).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and filling (D2331) provided on September 2, 2021, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised they accepted the 
enrollee's insurance. You say that the enrollee received a bill for these services. You say that the enrollee is on 
an extremely low income. You also say that the enrollee cannot afford this bill. The Plan denied your request. 
The Plan says dental services received out of network are not covered. The Plan also says that a prior 
authorization request for out of network services was not received. 
 
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, dental service received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2331) provided on September 2, 
2021, by the out of network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive to copayment for the emergency department services provided 
on September 26, 2021, through October 1, 2021. 
 
You asked the Plan to waive to copayment for the emergency department services. You say that you would like 
reconsideration for the services billed. The Plan denied your request. The Plan says this copayment has been 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Outpatient Hospital Observation.  
 You have been asked to pay a $90 copayment for the emergency department services. The emergency 
department services fall within the Outpatient Hospital Observation benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive to copayment for the emergency department services provided on September 26, 2021, through 
October 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the care can be received in another setting, such as at home, in a long-term care 
facility, or other outpatient setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show a BMI over 46 without chest diameter measurements. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance on June 9, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you went to an in-network provider for 
only a teeth cleaning, and you are not required to pay for any procedure you didn't request. You say that they 
informed you after that they were not in-network, and you need reimbursement. The Plan denied your request. 
The Plan says the claim reprocessed to fully pay for the periodic oral evaluation. The Plan also says that 
periodontal maintenance remains denied as a non-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, periodontal maintenance is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on January 14, 2022. 
 
You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) 
provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments  includes placement 
(D6057) and abutment supported porcelain fused to metal crowns (predominantly base metal) (D6060). 
 
You asked the Plan to pre-approve custom fabricated abutments and abutment supported crowns. You say that 
you need this service to have a healthy mouth. The Plan denied your request. The Plan says these services are 
not covered under your 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 
custom fabricated abutments  includes placement (D6057) and abutment supported porcelain fused to metal 
crowns (predominantly base metal) (D6060).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2100, V2744, V2750, V2783, 
V2797, V2799) provided on January 15, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are covered for these services, and feel this 
means they should have been covered at 100%. The Plan denied your request. The Plan says you are covered 
for $100 per year for routine eye wear. The original cost of the eyeglasses purchased on the date in question 
was $376. You are being asked to pay $226.40. 
 
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 covers these services up to $100 per year. 
 
We looked at the file and the Plan's rules. The documentation shows that your cost has been reduced from the 
original price by over $100. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses 
(V2020, V2100, V2744, V2750, V2783, V2797, V2799) provided on January 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions, alveoloplasty in conjunction with 
extractions, lingual frenectomy, and deep sedation services. 
 
You asked the Plan to pre-approve the dental services. You say that you need to have 11 teeth extracted. You 
also say that you need dentures. The Plan denied your request. The Plan the requested services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. The services you are asking the Plan to pre-approve 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 pre-approve surgical extractions, alveoloplasty in conjunction with extractions, lingual frenectomy, and 
deep sedation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an 
out-of-network provider on June 17, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you don't understand 
why a portion of the bill wasn't paid even if you used an out-of-network provider. You say that most plans 
cover preventive care, and something should have been paid. The Plan denied your request. The Plan says out-
of-network services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation and prophylaxis provided by an out-of-network provider on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is 
not medically 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. In addition, there are no objective 
exam findings provided for review. Overall, documentation is lacking regarding reasonably detailed and/or 
evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of 
the enrollees chronic persistent pain. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested 
procedure is not medically reasonable or necessary.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.