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

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray 
(D0220), and additional periapical x-rays (D0230 x 3) provided on December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed the x-rays to evaluate the extent of 
your teeth. You also say that these services should be covered. The Plan denied your request. The Plan says 
limited oral evaluation is not listed as a covered service. The Plan says that periapical x-rays are not listed as 
covered services either. 
 
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 limited oral evaluation and 
periapical x-rays 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), initial periapical x-ray (D0220), and additional periapical 
x-rays (D0230 x 3) provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient knee arthroscopy. 
 
You asked the Plan to pre-approve outpatient knee arthroscopy. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 outpatient knee arthroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 
outpatient knee arthroscopy, synovectomy limited, in this case, 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 outpatient knee arthroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient knee arthroscopy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively 
provide medically necessary and reasonable treatment in a SNF beyond the last covered date. Your functional 
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. As a practical matter this you do not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting beyond the last covered date. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you are new to hemodialysis via a catheter and 
may need further education regarding treatment. You have had a significant decline in physical functioning.  
There is no evidence in the documentation that you have repeatedly turned down physical therapy or 
occupational therapy services. Services were offered on 4/1/22, you were unavailable due to dialysis on 4/10/22 
and you declined services on 4/11/22. You require skilled therapy services on a daily basis at a skilled nursing 
facility to restore function and avoid further decline or complications. 
 
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 have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 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 dental services (D7210, D0150). 
 
You asked the Plan to pre-approve dental services. You say that this care is medically necessary. The Plan 
denied your request. The Plan says dental services are only covered when performed by a participating general 
dentist. 
 
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 dental 
services when they are performed by a participating general dentist. 
 
We looked at the file and Medicare rules. In this case, this is a request for dental services to be performed by an 
oral surgeon, not a general dentist. 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 pre-approve dental 
services (D7210, D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on August 12, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
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. The rendering dentist has opted-out until May 6, 2022. Therefore, we 
decided that the Plan does not have to pay for dental services provided by an opt-out provider on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial denture (D5213) provided on September 24, 2021. 
 
You asked the Plan to pay for the dental item. You say that dental implants and the prosthetic are married and 
form a single appliance. You say that the services should be covered as such. You also say that the service 
should be covered. The Plan denied your request. The Plan says partial dentures and implants share a frequency 
limit of once every 5 years. The Plan also says that the frequency limit has been exceeded. 
 
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 and partial denture is listed as covered, 
the frequency limit has been exceeded. The record shows that the partial dentures and implants share a 
frequency limit of once every 5 years. The record shows that the Plan paid for implant services that you 
received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 
partial denture (D5213) provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211), surgical placement 
of implant body: endosteal implant (D6010), prefabricated abutment (D6056), implant supported 
porcelain/ceramic crown (D6065), pontic (D6242), and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve a maxillary partial denture, endosteal implant, prefabricated abutment, 
implant supported porcelain/ceramic crown, pontic, and retainer crowns. You say that you have an infection 
and the dental office took x-rays. The Plan denied your request. The Plan says these services are for dental 
work for upper partial denture, implant, crowns, and false tooth for bridge. The Plan also says that the services 
requested are not a covered benefit and are excluded under 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5211), surgical placement of implant body: endosteal implant (D6010), 
prefabricated abutment (D6056), implant supported porcelain/ceramic crown (D6065), pontic (D6242), and 
two retainer crowns (D6740 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional surgical extraction (D7210) provided on 
December 29, 2021. 
 
You asked the Plan to pay for the additional extraction. You say that these services were done before the new 
year. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the 
frequency limitation has been exceeded. 
 
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, extractions are limited to three 
procedure codes per calendar year. The record shows that you received two simple extractions (D7140 x2) and 
one surgical extraction (D7210) on December 29, 2021 which were covered by the Plan, and your extractions 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional surgical 
extraction (D7210) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #14. 
 
You asked the Plan to pre-approve the crown. You say that your tooth is sharp and causing you a lot of pain. 
You need treatment for this tooth. The Plan denied your request. The Plan says tooth #14 has sub-crestal decay, 
which gives this tooth a poor long-term prognosis. A crown is not recommended as it would not save this tooth. 
 
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 the crown 
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 crown. Our reviewer says that the 
requested crown is not medically necessary in this case. Our physician reviewer found Tooth #14 has an 
existing two-surface restoration and a likely small buccal filling. There is some noted distal periodontal 
involvement with bone loss, though this may have been seen as sub-crestal decay by a prior review. There is 
however no substantial loss of tooth structure on #14 that would appear to require the strength of a full 
coverage crown. In general, crowns are considered where there is 50% or more missing tooth structure from 
decay or fracture. In this instance there is no more than 33% loss of total structure of the molar, and no cuspal involvement. Given the lack of structural damage to tooth #14, a crown would not be considered to be medically necessary. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown (D2740) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on December 22, 2021. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says this service is not 
a covered expense 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, 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 core 
buildup, including any pins when required (D2950) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that you believe your health may be 
jeopardized if the dentures cannot be repaired or you cannot get a new one. The Plan denied your request. The 
Plan says this 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is 
limited to one procedure every five plan years. The record shows that you received a complete maxillary 
denture (D5110) on December 31, 2020 and your complete maxillary denture (D5110) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture 
(D5110).
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 simple extraction (D7140) provided on November 4, 2021, and November 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and to pay more for the simple 
extraction. You say that you feel a false claim was made to the Plan as to what procedure was to be done. The 
Plan denied your request. The Plan says problem focused limited oral evaluation is not a covered expense 
under your dental plan, and the simple extraction processed correctly. The Plan says that when you contacted 
the Plan the first time, you were sent a copy of your code specific benefits which shows that only periodic oral 
exams are covered. The Plan also says that when you contacted the Plan the second time about extractions, you 
were advised that extractions were covered at 50% of the contracted rate for an in-network provider, which is 
how the claim was processed. 
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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract also says that you are 
responsible for a 50% coinsurance for extractions that are provided in-network. Therefore, we decided that the 
Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the simple 
extraction (D7140) provided on November 4, 2021, and November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist thinking all of the 
services would be covered. You say that you do not have money to pay for these services. You also say that 
you need help. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once 
every 3 years. The Plan says complete series x-ray is covered once every 5 years. The Plan also says that the 
frequency limit has been exceeded. 
 
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you 
received on October 8, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) and complete series x-ray (D0210) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), and a comprehensive oral evaluation 
(D0150) provided by an out-of-network provider on December 16, 2021. 
 
You asked the Plan to pay for prophylaxis and a comprehensive oral evaluation. You say that you would like 
the Plan to pay for the rest of the bill. The Plan denied your request. The Plan says this claim has been 
processed correctly. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis and a comprehensive oral evaluation have been processed correctly. Therefore, we 
decided that the Plan does not have to pay for prophylaxis (D1110), and a comprehensive oral evaluation 
(D0150) provided by an out-of-network provider on December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's high functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural injections (TFESIs). 
 
You asked the Plan to pre-approve TFESIs. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and 
necessary to perform TFESIs at more than two (2) nerve root levels during the same session. 
 
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 TFESIs. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found according to the coverage criteria, it is not 
considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels 
during the same session. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TFESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal epidural injections (TFESIs).