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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the denture. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is covered by the Plan's dental benefits; however, your benefit 
for one maxillary partial denture (D5225) has 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. The Plan covers one maxillary 
partial denture (D5225) every 60 months. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a maxillary 
partial denture provided on January 11, 2022; therefore, the benefit for one maxillary partial denture has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 3, 2022, to March 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you were unaware that this provider was out-of-
network. The Plan denied your request. The Plan says services provided by an out-of-network provider 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 provided by a participating provider. 
 
We looked 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 dental 
services provided by an out-of-network provider on March 3, 2022, to March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940) provided on February 3, 2022. 
 
You asked the Plan to pay for protective restoration. You say that a representative told you that you had a 
$1,000 for the year and that it would cover all dental services. The Plan denied your request. The Plan says 
protective restoration (D2940) is 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 protective 
restoration (D2940) provided on February 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided February 15, 
2022, through March 3, 2022. 
 
You asked the Plan to pay for continued SNF care. You say that continued SNF care should be covered. The 
Plan denied your request. The Plan says the enrollee has exceeded the 100-day SNF limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
 The file shows that the enrollee received 100 days of SNF care during the benefit period from October 14, 
2021, to February 14, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided February 15, 2022, 
through March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant crown (D6066) provided on March 15, 2022. 
 
You asked the Plan to pay for the implant crown. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an implant crown (D6066) is not covered by your supplemental 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant crown (D6066) provided on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation 
(CCM) system. 
 
You asked the Plan to pre-approve an Optimizer Smart CCM system. 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 an Optimizer Smart CCM system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system is not considered to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Optimizer Smart CCM system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation (CCM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain crown (D2750) provided on February 22, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy. 
 
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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown 
(D2750) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on December 27, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dental exam was unprofessional. You say 
that you feel the services were incorrectly reported. You say you were billed for services not rendered. You 
also say that you should not be responsible for this bill. The Plan denied your request. The Plan says complete 
series x-ray is not listed as a covered service. 
 
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 complete series x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete 
series x-ray (D0210) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial dentures (D5213) and mandibular 
partial dentures (D5214). 
 
You asked the Plan to pre-approve dentures. You say that you want the dentures covered. The Plan denied your 
request. The Plan says maxillary partial dentures (D5213) and mandibular partial dentures (D5214) are not 
covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
maxillary partial dentures (D5213) and mandibular partial dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extraction (D7210), and inhalation of nitrous 
oxide (D9230) provided on June 1, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that this claim was misrouted multiple 
times. You say that you were finally advised to submit an appeal. You also say that you should be reimbursed 
for these services. The Plan denied your request. The Plan says anesthesia required for an uncovered procedure, 
extraction, is also 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 extraction is not among those 
covered under this benefit. Additionally, the services you are asking the Plan to reimburse you 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 reimburse you for the extraction (D7210), and inhalation of nitrous oxide (D9230) provided on 
June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), and oroantral fistula closure (D7260) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the endosteal implant, bone graft, and oroantral fistula closure. You say that prior 
to the appointment you spoke with a Plan representative who advised you that the treating provider was in-
network. The Plan denied your request. The Plan says these services are not covered expenses 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 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 pay for the 
surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant placement 
(D6104), and oroantral fistula closure (D7260) provided on January 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) visits. 
 You asked the Plan to pre-approve six additional PT visits. You say that the patient is still in need of physical 
therapy. The Plan denied your request. The Plan says six physical therapy visits are denied as not reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 pay for six additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not part of a maintenance program. Our 
physician reviewer also found that 12 visits of additional physical therapy are not required to establish a home 
exercise program. Our physician reviewer also found that the six visits provided should suffice given that the 
patient is already performing exercises at home and her range of motion and motor strength is close to normal. 
Our physician reviewer also found that the requested additional physical therapy cannot be considered 
medically necessary given the fact that the guideline criteria have not been 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 six additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture provided on August 23, 2021, and August 31, 2021. 
 
You asked the Plan to pay for acupuncture. You say that you were told this was denied because claims for 22 
dates of service were submitted instead of 20. You say that you do not understand why you were denied 
reimbursement. The Plan denied your request. The Plan says that the acupuncture provided from March 2, 
2021, through August 22, 2021, were processed. The Plan also says the acupuncture provided on August 23, 
2021, and August 31, 2021, remain denied as exceeding the Plan benefit limit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of acupuncture provided on August 23, 2021, and August 31, 2021, have been met. Although multiple 
acupuncture services were provided on two dates of service, only 20 dates of service were billed. The records 
do not support that two acupuncture visits prior to this claim were paid to exhaust your benefit. Therefore, we 
decided that the Plan has to pay for acupuncture provided on August 23, 2021, and August 31, 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.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and a panoramic x-ray 
(D0330) provided on March 9, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that you had to begin seeing a new dentist this 
year. You also say your old dentist closed his office and you were unable to obtain your records. The Plan 
denied your request. The Plan says that your benefits for these services has been exhausted. 
 
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 evidence that the benefit for these services has been 
previously exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation 
(D0150) and a panoramic x-ray (D0330) provided on March 9, 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 pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on December 9, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You 
say that you were assured periodontal services would be covered, including the examination. The Plan denied 
your request. The Plan says these services are not covered expenses 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 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 pay for the first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride varnish (D1206) and periodontal 
maintenance (D4910) provided on March 10, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you feel the services should be covered. The 
Plan denied your request. The Plan says dental 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride varnish and periodontal 
maintenance are not among those covered under this benefit when provided by an out of network dentist.  
 
Therefore, we decided that the Plan does not have to pay for the application of fluoride varnish (D1206) and 
periodontal maintenance (D4910) provided on March 10, 2022, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia procedure (99135) provided on 
January 27, 2022.  You asked the Plan to pay for the special anesthesia procedure (99135). The Plan denied 
your request. The Plan says bundled services are not eligible for separate payment. 
 
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 99135 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99135 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia procedure (99135) have not been met. Therefore, we decided that the Plan does not 
have to pay for the special anesthesia procedure (99135) provided on January 27, 2022.