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

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), fluoride varnish (D1206), and a crown repair (D2980) provided by an out-of-network provider on 
June 6, 2022, to June 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to 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. D2980 
is not a covered benefit. Therefore, we decided that the Plan does not have to pay more for a periodic oral 
evaluation (D0120), prophylaxis (D1110), fluoride varnish (D1206), and a crown repair (D2980) provided by 
Stephen White, D.D.S., on June 6, 2022, to June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0230, D0220) provided on July 11, 2022. 
 
You asked the Plan to pay for the intraoral x-rays. 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 fall 
within 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 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 intraoral 
x-rays (D0230, D0220) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) and non-intravenous 
conscious sedation (D9248) and waive the coinsurance for an extraction (D7210), provided by a participating 
provider on July 8, 2022. 
 
You asked the Plan to pay for a bone replacement graft and non-intravenous conscious sedation and waive the 
coinsurance for an extraction. You say that you believe the Plan should be paying more. The Plan denied your 
request. The Plan says D7953 and D9248 are not covered benefits. D7210 was processed correctly. 
 
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, D7953 and D9248 are not among those 
covered under this benefit. The total allowed amount for D7210 is $209. The total amount you are being asked to pay is $104.50 ($209 x 50% = $104.50). Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft and non-intravenous conscious sedation and waive the coinsurance for an extraction provided 
by a participating provider on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays and root canals provided on July 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for x-rays and root canals. You say that you are in pain and really need this service. 
The Plan denied your request. The Plan says these services are not covered by an out-of-network provider. 
 
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 x-rays and root canals provided on July 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 the resin-based composite (D2391) and two additional 
amalgams (D2140 x2) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot pay for these services. 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 April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2391) and two 
additional amalgams (D2140 x2) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction 
 
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, the record does not indicate that you have one root or 
excessive bone loss. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
tooth extraction
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 16, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you had a root canal on tooth number 14 
provided by this provider on August 16, 2022. You also say that you were referred by your dentist. 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 August 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944) provided by a participating 
provider. 
 
You asked the Plan to pre-approve an occlusal guard. You say that you need a new mouth guard. You say that 
you have cracked a tooth while waiting for this approval. The Plan denied your request. The Plan says the 
requested dental guard 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 pre-approve an 
occlusal guard (D9944) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tissue materials added to help healing (D4265) and gum 
surgery (D4273) Tooth #31. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services. The Plan 
denied your request. The Plan says this service is not covered under your 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. Tissue materials added to help 
healing (D4265) and gum surgery (D4273) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Tissue materials added to 
help healing (D4265) and gum surgery (D4273) Tooth #31 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve tissue materials added to help healing 
(D4265) and gum surgery (D4273) Tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical first 
radiographic image (D0220) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you began using a prescribed oral rinse for an 
ulcer on your gums, and the ulcer did not seem to get smaller. You also say that then you made an emergent 
appointment with your dentist. 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 Plan's 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 May 23, 2022, for the 
limited oral evaluation (D0140), and on October 25, 2021, for the periapical radiographic image (D0220). 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical 
first radiographic image (D0220) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for the gum irrigation, topical fluoride, and cleaning provided on July 
27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to fully pay for 
the dental services. The Plan denied your request. The Plan says that the enrollee met their yearly dental 
maximum amount. 
 
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 submit the EOC to show what the enrollees yearly dental 
benefit maximum is. This means that we cannot determine if the Plan was correct to not fully pay for the dental 
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 more 
for the gum irrigation, topical fluoride, and cleaning provided on July 27, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at a SNF. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary for the enrollee to continue 
to receive SNF care. The Plan denied your request. The Plan says the enrollee no longer required skilled 
services on a daily inpatient basis and the enrollee can receive the therapy they need at an outpatient or 
residential long-term care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested continuation of a SNF stay is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a SNF setting. The enrollees care needs can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continued stay at a SNF.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0150, D0210, D1110) provided on July 20, 
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 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 dental services (D0150, D0210, D1110) provided on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating per lens (V2750 x2) and the 
dispensed vision item (V2799) provided on May 12, 2022. 
 
You asked the Plan to pay for the single vision per lens (V2100 x2) the anti-reflective coating per lens (V2750 
x2) and the dispensed vision item (V2799). You say that you should be reimbursed for the glasses you received 
after your cataract surgery. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover upgrades (tinting, scratch-resistant lenses, and designer frames). 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered services. Based on this 
information, we decided that the Plan's rules for coverage of the anti-reflective coating per lens (V2750 x2) and 
the dispensed vision item (V2799) have not been met. Therefore, we decided that the Plan does not have to pay 
for the anti-reflective coating per lens (V2750 x2) and the dispensed vision item (V2799) provided on May 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee, flexible 
protective outer surface covering system (L5964). 
 
You asked the Plan to pre-approve the flexible protective outer surface covering. You say that the medical 
records provided support the necessity of the requested service. The Plan denied your request. The Plan says 
this item is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Medicare rules says when an above knee preparatory 
prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or additions of procedures and 
components are covered in accordance with the functional level assessment except for codes L5624, L5631, 
L5648, L5651, L5652, L5705, L5706, L5964, and L5966 which will be denied as not reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage of the flexible protective 
outer surface covering have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
addition, endoskeletal system, above knee, flexible protective outer surface covering system (L5964).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate maxillary and mandibular denture (D5130 and 
D5140) provided by a participating provider on July 22, 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 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 annual dental allowance amount was exhausted on date of service May 12, 2022. Therefore, we 
decided that the Plan does not have to pay for an immediate maxillary and mandibular denture (D5130 and 
D5140) provided by a participating provider on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and need new dentures. 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 Plan's 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 the date of service of October 15, 2018. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a complete maxillary denture and a partial mandibular denture. You say that 
you believe these dentures should be covered. The Plan denied your request. The Plan says dentures are 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 pre-approve a 
complete maxillary denture (D5110) and a partial mandibular denture (D5214) provided by an out-of-network 
provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on review of 
the clinical information provided the request for services is not reasonable or necessary. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for subarachnoid hemorrhage. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided a in a different level of 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 IRF admission and services.