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

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic 
oral evaluation (D0120), and prophylaxis (D1110) provided on May 12, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware this provider was no longer 
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 the bitewings - four radiographic images (D0274), periodic oral evaluation (D0120), and prophylaxis 
(D1110) provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the onlay - resin-based composite - four or more surfaces 
(D2664) and limited oral evaluation - problem focused (D0140) provided May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental provider did not confirm if the 
services were covered. The Plan denied your request. The Plan says your benefit for the limited oral exam has 
already been exhausted. The onlay 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, certain limitations apply. The record 
shows your benefit for the limited oral exam was exhausted on date of service March 22, 2022. The onlay is 
not covered under your benefits. Therefore, we decided that the Plan does not have to pay for the onlay - resin-
based composite - four or more surfaces (D2664) and limited oral evaluation - problem focused (D0140) 
provided May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral x-
ray (D0210) provided on May 12, 2022. 
 
You asked the Plan to pay for 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 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 March 17, 2022 and 
April 11, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) and an intraoral x-ray (D0210) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodic oral evaluation (D0120), dental 
cleaning (D1110), and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) provided from May 17, 2021, through May 26, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are 
not payable as the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until June 1, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to issue reimbursement for the periodic oral evaluation (D0120), dental cleaning (D1110), 
and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided 
from May 17, 2021, through May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) and an extraction (D7210) 
provided by an out-of-network provider on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says 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 resin-based composite (D2331) and an extraction (D7210) provided by an out-of-network provider 
on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spinal surgery services (22552, 20930, 22845, 22853) 
provided on February 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for spinal surgery services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for OON care have 
not been met.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for spinal surgery services (22552, 20930, 22845, 
22853) provided on February 11, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940) provided by a participating 
provider on March 29, 2022. 
 
You asked the Plan to pay for protective restoration. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for protective 
restoration (D2940) provided by a participating provider on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 29, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service February 24, 2021. Specifically, 
the Plan covers one comprehensive oral exam every three plan years. You previously received this service on 
February 24, 2021, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for 
this service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought that this would be covered and 
paid. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided by an out-of-network provider 
on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford these charges. 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 21, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite fillings on tooth #6 and 7 
(D2332) and does not have to pay for diagnostic casts (D0470) provided on May 2, 2022, and a crown (D2740) 
and core build up (D2950) provided on May 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services were medically necessary 
due to a medical condition. The Plan denied your request. The Plan says that diagnostic casts (D0470), crowns 
(D2740), and core build up (D2750) are not covered by your routine dental benefits. The Plan also says that 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, diagnostic casts, crowns, and core 
build up are not among those covered under this benefit. 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 
resin-based composite fillings on tooth #6 and 7 (D2332) and does not have to pay for diagnostic casts (D0470) 
provided on May 2, 2022, and a crown (D2740) and core build up (D2950) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment on tooth #13 (D6057) and an 
abutment supported crown on tooth #13 (D6059) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a custom fabricated abutment (D6057) and an abutment supported 
crown (D6059) 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 pay for a custom 
fabricated abutment on tooth #13 (D6057) and an abutment supported crown on tooth #13 (D6059) provided on 
May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial maxillary and mandibular denture (D5225 and 
D5226) provided by an out-of-network provider on April 22, 2021. 
 
You asked the Plan to pay for a partial maxillary and mandibular denture. You say that these dentures are 
medically necessary. The Plan denied your request. The Plan says the rendered dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial maxillary and mandibular denture (D5225 and D5226) provided by an out-of-network provider on April 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a prefabricated post and core in addition to a crown on tooth #3 
(D2954) provided on March 9, 2022. 
 
You asked the Plan to pay for a prefabricated post. You say that this service should be covered. The Plan 
denied your request. The Plan says that the requested procedure is denied since the medical necessity is not 
evident from the submitted documentation. 
 
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 the medical records they used in making their decision. 
They did not support their decision to deny your request. Therefore, we decided that the Plan has to pay for a 
prefabricated post and core in addition to a crown on tooth #3 (D2954) 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 gingival irrigation (D4921) provided by a contracted 
provider on May 3, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the rendered dental services are not covered 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 gingival 
irrigation (D4921) provided by a participating provider on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), a resin-based composite filling on tooth #28 (D2391), and extractions of tooth #30 and 32 (D7210) 
provided on May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says 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 limited oral evaluation (D0140), a periapical x-ray (D0220), a resin-based composite filling on 
tooth #28 (D2391), and extractions of tooth #30 and 32 (D7210) provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 you fell and fractured your hip. You say that you 
cannot leave the house, get dressed, or use the restroom on your own without risk of falling. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services 
needed can be provided safely in other settings. 
 
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.  Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical conditions are reported to be stable on outpatient medications with no issues that require a physicians 
evaluation three or more times per week. The enrollee does require physical therapy and occupational therapy 
services, but the medical records provided do not clarify why the enrollee requires an intensive inpatient 
rehabilitation therapy program. Provided records do not explain why the intensive inpatient rehabilitation 
therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of the expandable control system. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk for falling. The 
Plan denied your request. The Plan says the enrollee has adequate upper limb strength to operate the power 
features with their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee is non-ambulatory and cannot stand but is able to independently transfer. She 
was last evaluated for a power wheelchair in June 2019. At that time, the documentation provided indicates that 
she had 3/5 motor strength in the upper extremities and perform transfers. Therefore, she should have sufficient 
strength to operate the power options through their own switches and the requested expandable controller does 
not meet the guideline criteria. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement of the expandable control system.