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

 
We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on November 19, 2021. 
 
You asked the Plan to pay for the dental service. You say that the office staff advised this procedure was 
covered under your policy. You also say that you received a bill after a few months. The Plan denied your 
request. The Plan says porcelain crown 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 porcelain crown is not among those 
covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on 
November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported porcelain crown (D6059) provided by an out-of-network provider on February 2, 2022. 
 
You asked the Plan to pay for a custom fabricated abutment and an abutment supported porcelain crown. You 
say that crowns should be covered at a 50% coinsurance. The Plan denied your request. The Plan says D6057 
and D6059 are not covered 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 (D6057), and an abutment supported porcelain crown (D6059) provided by an out-of-
network provider on February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need such as therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass 
grafting. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oral exam (D0120), and prophylaxis (D1110) 
provided on April 5, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you were unaware that you needed to 
change dental providers. You also say that you feel you should be reimbursed. The Plan denied your request. 
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be 
made to providers that have opted out of Medicare. 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the oral exam (D0120), and prophylaxis (D1110) provided on 
April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on November 6, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says this 
claim was received on November 29, 2021. The Plan also says that this is past the allowed 12-month 
timeframe. 
 
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 the problem focused limited oral evaluation and first intraoral periapical x-
ray was not filed until November 29, 2021. 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 pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is 
medically necessary after elective surgery. The Plan denied your request. The Plan says there is no need for the 
enrollee to be admitted for inpatient care after elective surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the reviewed documentation indicates that the enrollee is undergoing a 
planned total shoulder arthroplasty, biceps tenodesis, and capsular contracture release. The enrollee is 
medically stable and has been provided medical clearance to undergo this elective procedure. The planned 
procedures are not listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure 
is currently approved as an ambulatory procedure. There is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record 
does not show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier emergency department and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the resin based composites (D2394, D2392), pulp cap 
(D3120 x 2), sales tax (D9985), and amalgam (D2150) provided from January 18, 2022, to February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you contacted customer service prior to 
receiving services. You say that you were advised out of network dental claims were paid at a lesser rate than 
in network providers. You also say that you feel you should not be penalized for the full amount of the denial. 
The Plan denied your request. The Plan says the services you received are not listed as covered services. The 
Plan says that during the phone call in January 2022, you did not question any benefits or specific coverage. 
The Plan also says that no misinformation was given. 
 
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 dental services you received are not 
among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that 
the Plan does not have to pay for the resin based composites (D2394, D2392), pulp cap (D3120 x 2), sales tax 
(D9985), and amalgam (D2150) provided from January 18, 2022, to February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement for teeth #29 and #30 (D6010), 
abutment supported cast metal crown (high noble metal) for teeth #29 and #30 (D6062) and a custom abutment 
for teeth #29 and #30 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is only covered when medically necessary, and when a single tooth is 
missing in the arch. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary.   
Our physician reviewer found based on the provided information, the requested implants are not medically 
necessary.  The x-rays show sever periodontal disease around the remaining roots of #29 and #30, and the 
quality and volume of bone may not be adequate to allow for implant placement without bone 
augmentation. The requested implants would not be reasonable and necessary at this time without addressing 
the bone concerns. The Plan criteria for implants allow for one implant per arch where there are no other 
missing teeth in the arch (unless to be used with an implant retained denture). In this case there are two 
adjacent missing teeth in the lower arch, with a notable amount of  missing bone support. As the Plan does not 
allow for implants in an arch with more than one missing tooth, and no more than one implant in an arch, the 
criteria for implant restorations has not been met. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve implant placement for teeth #29 and #30 (D6010), abutment supported cast metal 
crown (high noble metal) for teeth #29 and #30 (D6062) and a custom abutment for teeth #29 and #30 (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair mounted robotic arm (K0108x1) and 
associated labor costs, repair or nonroutine service for durable medical equipment other than oxygen equipment 
requiring the skill of a technician, labor component, per 15 minutes (K0739x12) 
 
You asked the Plan to pre-approve the robotic arm and associated labor costs. You say that attached please find 
the documents for review on the prior authorization request. 
 The Plan denied your request. The Plan says the requirements are not met because the records does not support 
medical necessity of requested accessories. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the robotic arm and associated labor 
costs. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the labor for the mounting of the wheelchair is 
not considered durable medical equipment. Furthermore, the enrollee resides in a care facility that provides 24 
hour assistance. The requested wheelchair robotic arm is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the robotic arm and associated labor costs have not been met. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair mounted robotic arm (K0108x1) and associated 
labor costs, repair or nonroutine service for durable medical equipment other than oxygen equipment requiring 
the skill of a technician, labor component, per 15 minutes (K0739x12)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted neurological or neuromuscular diagnostic procedure (CPT Code 95999) provided to the enrollee on July 1, 2019.

You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Based on Medicare guidelines, the payment for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic procedure) you and/or your provider is/are requesting does not meet the requirements for approval. We reviewed your records and they show that you had spinal surgery. The record sent by your provider indicates that you underwent back surgery requiring neurophysiology monitoring. Other neuromonitoring services have been approved for payment by the Plan. Medicare guidelines say that this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure. Under Medicare guidelines, your request is not a covered benefit because Medicare does not make separate payment for this service. We are unable to approve this request. The enrollee will not be responsible for this payment as the cost is included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for unlisted neurological or neuromuscular diagnostic procedure (CPT Code 95999) provided to the enrollee on July 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 
(CPT code 22513). 
 
You asked the Plan to pre-approve the service. You say that you are unable to get around due to your pain and 
have not been able to sleep in bed for three (3) months. The Plan denied your request. The Plan says your 
request is not medical necessary because your records show you fractured your backbone in under twelve (12) 
weeks from the submitted procedure date (April 14, 2022). 
 
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 service. Our physician reviewer 
found the records show that the fracture is more than twelve (12) weeks old. Criteria not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; thoracic (CPT code 22513).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010). 
 
You asked the Plan to pre-approve endosteal implants. You say that you really need the dental implants so you 
can eat. The Plan denied your request. The Plan says implants are 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 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 
surgical placement of implant body: endosteal implants (D6010).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 23, 2021, to 
October 25, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation shows that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 23, 2021, to October 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that your doctor referred you because this provider 
has the shoes you need. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan confirmed that the network 
provider has the shoes that you need. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve foot orthotics from an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on June 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you relied on the test from your 2021 Evidence 
of Coverage that your dental services would be covered. You say that it indicates up to $400 will be paid every 
year for non-Medicare covered preventive and comprehensive dental services. The Plan denied your request. 
The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be 
made to a provider that has opted out of Medicare. 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the crown (D2750) provided on June 1, 2021.