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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous provider retired, and this is a new 
dental provider. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 17, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on August 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay beyond 
October 29, 2022. 
 
You asked the Plan to pre-approve a continued SNF stay. The Plan denied your request. The Plan says this case 
is late and was auto-forwarded by the Plan because the Plan missed the timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a continued SNF stay have been met. 
Medical records were not provided for this case. The Plan attempted to obtain this information, but it was not 
received. Without medical records, we are unable to determine if the requested SNF services are medically 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a continued skilled 
nursing facility (SNF) stay beyond October 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies (K0553), provided on April 10, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the date of service does not match the shipping or delivery date as required 
by the Center for Medicare & Medicaid Services (CMS). 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The date of service 
does not match the shipping or delivery date as required by the Center for Medicare & Medicaid Services 
(CMS). The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic supplies (K0553), provided 
on April 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have this cleaning done every 6 months. 
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 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on August 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and
pelvis.
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. The Plan denied your request. The
Plan says this request cannot be approved at this time.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 a CT scan of the abdomen and pelvis.
Our physician reviewer found the record indicates that the enrollee has weight loss and steatorrhea without
abdominal pain. The record does not indicate that laboratory evaluation or basic imaging has been performed.
Our reviewer found that the provided records are insufficient to establish the medical necessity or
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are not satisfied. Our physician reviewer also found that the requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan of the abdomen and pelvis have not been met. Therefore, we decided
that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on February 28, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 
comprehensive periodontal evaluation (D0180) provided on February 28, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 30, 2022, to 
June 13, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you are appealing the denied services. The Plan 
denied your request. The Plan says that the enrollee reached their 100 days of SNF benefits by May 30, 2022. 
 
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. There is no documentation of how long the first admission date was. Therefore, 
we have no proof the 100 days of the SNF care was met by May 20, 2022, and that there was not at least 60 
days between both of the admission dates. This means that we cannot determine if the Plan was correct to not 
pay for the SNF care for the dates of services. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 30, 2022, to June 
13, 2022.  
 
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 a 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 the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 (D2750)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging 
(D0220 and D0230), and a panoramic radiographic image (D0330), provided by an out-of-network provider on 
July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought this provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), intraoral imaging (D0220 and D0230), and a panoramic 
radiographic image (D0330), provided by an out-of-network provider on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for dental services (D9944, D0171, D2740, 
D2751) provided on July 14, 2022 to July 22, 2022. 
 
You asked the Plan to waive the cost-sharing 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 the cost-sharing applied 
correctly based on the services provided. 
 
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.    
 
You have been asked to pay a $100 deductible and 50% coinsurance for dental services. 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 the cost-sharing for dental services (D9944, 
D0171, D2740, D2751) provided on July 14, 2022 to July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) and a recement of a crown 
(D2920) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed the dental procedure done again but 
it was not done properly the first time. 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 items or services was exhausted on the date of service of July 6, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) and a recement of a 
crown (D2920) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 19, 2022. 
 
You asked the Plan to pay for a limited oral evaluation (D0140) \. You say that the oral evaluation is required 
by the dentist, so this should not be a denied benefit. The Plan denied your request. The Plan says if you 
receive a service not listed on the table in the EOC, you will have to pay the full cost. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture - cast metal framework with resin denture bases 
(D5213). You say that you need to have dentures done because other people hit you and broke your teeth. The 
Plan denied your request. The Plan says a partial denture is not medically necessary because the remaining 
teeth do not show healthy gums and good bone support. 
 
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 a maxillary 
partial denture - cast metal framework with resin denture bases (D5213) 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 a maxillary partial denture - cast metal 
framework with resin denture bases (D5213). Our reviewer says that the service is not medically necessary. 
Our physician reviewer found several of the abutment teeth have up to 50% of the supporting bone missing, 
making them unsuitable for clasping. Our physician reviewer also found that a tissue supported partial denture 
would be appropriate in this situation as it would not utilize the weakened teeth for support. 
 
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 a maxillary partial denture - cast metal framework with resin denture bases 
(D5213) have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary 
partial denture - cast metal framework with resin denture bases (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade with harness and 
electronic connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that an expandable controller is used to control 
multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the expandable controller and harness upgrade 
with electronic connection are not needed to control the approved power switches. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller upgrade with harness and electronic 
connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a prefabricated post cand core build-up (D2954) and 
endodontic therapy (D3330) provided by an out-of-network provider on July 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like the Plan should pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for endodontic therapy (D3330) or pay for a 
prefabricated post cand core build-up (D2954) provided by an out-of-network provider on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an emergency palliative treatment (D9110) 
provided by a participating provider on June 27, 2022. 
 
You asked the Plan to waive the deductible for an emergency palliative treatment. You say that you disagree 
with the amount you are being charged. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $50 deductible which applies to dental services.  
 
The item or service you asked the Plan to waive the deductible for falls within the dental services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $50 
deductible which applies to dental services. This cost sharing is a contractual obligation that had not been met 
at the time an emergency palliative treatment was received on June 27, 2022. Therefore, we decided that the 
Plan does not have to waive the $38 deductible for an emergency palliative treatment (D9110) provided by a 
participating provider on June 27, 2022.
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 July 14, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you believe the Plan should pay for the 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 July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
August 10, 2022. 
 
You asked the Plan to pay for dental services. You say that the service should be covered with no out-of-pocket 
charge. The Plan denied your request. The Plan says the service is covered but limitations apply. 
 
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. This benefit includes 
bitewings - two radiographic images (D0272) one set of x-rays, two times per year. 
 
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. The Plan agreed to pay for bitewings - two radiographic images 
(D0272). This leaves an amount of $9 cost share that you are responsible for. Therefore, we decided that the 
Plan does not have to pay for bitewings - four radiographic images (D0274) provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4556 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code A4556. You say that this code was medically necessary and 
should be paid. The Plan denied your request. The Plan says procedure code A4556 is considered bundled and 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4556 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4556 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code A4556 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4556 billed for date of service June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on July 20, 222, and extraction, erupted tooth or exposed root (elevation and/or forceps removal) 
tooth #12 (D7140) provided on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was a medical problem as much as a dental 
problem. You also say that no creditable dentist would pull a tooth without an examination. 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 limited 
oral evaluation - problem focused (D0140) is not covered by the Plans dental benefits. The record shows your 
benefit for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) was 
exhausted on date of service July 20, 2022. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation - problem focused (D0140) provided on July 20, 222, and extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) tooth #12 (D7140) provided on August 11, 2022.