Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vacuum-assisted socket system and shock reducing 
pylon (CPT code(s): L5988 and L5781). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says this vacuum socket is experimental and cannot be approved. The Plan states the notes do 
not show why the upgraded pylon is medically needed. 
 
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 items. Our physician reviewer 
found you have been authorized to have K3-level replacement prosthesis. There is no documentation by the 
provider to support the need for the additional shock reducing pylon. The requested vacuum-assisted socket 
system has not been shown to be superior to other standard treatments for the medical condition. The requested 
component parts are 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the vacuum-assisted socket system and shock reducing pylon (CPT code(s): L5988 and L5781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
provided by a participating provider. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation. You say that you would like 
the Plan to approve and pay for these services. The Plan denied your request. The Plan says the requested 
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 pre-approve bone 
replacement graft for ridge preservation (D7953) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage implant surgery (D6011) provided by a 
participating provider. 
 
You asked the Plan to pre-approve second stage implant surgery. You say that you would like the Plan to 
approve these services, The Plan denied your request. The Plan says the requested services are not 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 
second stage implant surgery (D6011) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
You asked the Plan to pay more for the dental services. You say that there are no in-network providers taking 
new patients. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), topical application of 
fluoride varnish (D1206), onlay-porcelain/ceramic (D2643) and resin-based composite (D2331) provided on 
November 28, 2017. 
 
You asked the Plan to pay for the dental services. You say that claims are being filed fraudulently. The Plan 
denied your request. The Plan says records indicate the claims were submitted over the 12 month claim filing 
limitation. 
 
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 dental services was not filed until April 19, 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 pay for periodontal maintenance (D4910), topical application of fluoride varnish 
(D1206), onlay-porcelain/ceramic-three surfaces (D2643) and resin-based composite - two surfaces (D2331) 
provided on November 28, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration on tooth #2, 4, 14, and 15 
(D4266) and bone replacement graft on tooth #2, 4, 14, and 15 (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says guided tissue regeneration (D4266) and bone replacement grafts 
(D7953) are 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 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 
guided tissue regeneration on tooth #2, 4, 14, and 15 (D4266) and bone replacement graft on tooth #2, 4, 14, 
and 15 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond inlay, onlay, veneer or partial 
coverage restoration (D2910) and re-cement or re-bond crown (D2920) provided on April 13, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond inlay, onlay, veneer or partial coverage restoration and 
re-cement or re-bond crown. You say that you think you should be reimbursed at least $275. The Plan denied 
your request. The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond inlay, onlay, veneer or partial coverage restoration (D2910) and re-cement or re-bond crown 
(D2920) provided on April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have waive the $825 copayment for an inpatient hospital stay from  
March 26, 2022, to March 29, 2022. 
 
You asked the Plan waive the $825 copayment for an inpatient hospital stay. You say that you do not know 
why you are being billed. The Plan denied your request. The Plan says the copayment has been applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
per day copayment for Inpatient Hospital Care.  
 
You have been asked to pay a $825 ($275x3days=$825) copayment for an inpatient hospital stay. An inpatient 
hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have waive the $825 
copayment for an inpatient hospital stay from March 26, 2022, to March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) and precision attachment 
(D6950), provided by a participating provider on May 12, 2022. 
 
You asked the Plan to pay for a prefabricated abutment and precision attachment. You say that you need these 
services done for your overall health. The Plan denied your request. The Plan says the dental work that was 
provided 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 
prefabricated abutment (D6056) and precision attachment (D6950), provided by a participating provider on 
May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. The Plan denied your request. The Plan says 
this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), resin-
based composite of two surfaces (D2331), resin-based composite of three surfaces (D2332), and three resin-
based composites of four or more surfaces (D2335 x3) provided on April 12, 2021. 
 
You asked the Plan to pay for the topical application of fluoride varnish and resin-based composites. You say 
that you have damage to your teeth from medical conditions. The Plan denied your request. The Plan says these 
services 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. 
 
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 
topical application of fluoride varnish (D1206), resin-based composite of two surfaces (D2331), resin-based 
composite of three surfaces (D2332), and three resin-based composites of four or more surfaces (D2335 x3) 
provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 & D4342) 
provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
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 July 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 & D4342) 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary complete dentures (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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, 2018. 
Therefore, we decided that the Plan does not have to pre-approve maxillary complete dentures (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the desensitizing medicament (D9910) for tooth #11. 
 
You asked the Plan to pre-approve the desensitizing medicament. You say that you would like the Plan to cover 
this service so the dentist can finish the process. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because desensitizing medicament is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
desensitizing medicament (D9910) for tooth #11.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection for the enrollee. 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says that the clinical value and effectiveness of Platelet Rich Plasma 
Injection in the setting of a revision of total knee arthroplasty have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that PRP injections are considered to be experimental 
and investigational.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a platelet rich plasma injection has not been met. Therefore, we decided that the Plan does not have 
to pre-approve a platelet rich plasma (PRP) injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a dental exam and x-rays provided on March 3, 2022. 
 
You asked the Plan to pay for a dental exam and x-rays. You say that these services were necessary. The Plan 
denied your request. The Plan says that these services exceed the maximum allowable. 
 
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 has not provided the Evidence of Coverage or other documentation 
showing the rules of the Plan's dental benefit. Without this information, the Plan's denial reasoning cannot be 
verified. Therefore, we decided that the Plan has to pay for a dental exam and x-rays provided on March 3, 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 core buildup, including any pins when required (D2950) 
provided on May 9, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you were told services would be 100% covered. 
The Plan denied your request. The Plan says this is not a covered service under your dental benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins when required (D2950) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and bitewing x-rays (D0277) 
provided on April 12, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says that your benefit for a comprehensive oral evaluation 
(D0150) has already been exhausted. The Plan also says that bitewing x-rays (D0277) are not covered by your 
dental benefits. 
 
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 showing your benefit for a comprehensive 
oral evaluation has been exhausted. According to the EOC, bitewing x-rays are covered under your dental 
benefits. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and 
bitewing x-rays (D0277) provided on April 12, 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 more for prophylaxis-adult provided on April 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reimbursement for this 
claim. 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. The Plan has followed Medicare rules by clearly disclosing in the contract that if you choose an out-
of-network provider you pay 50% coinsurance. The allowed amount is $68 (50% of $68 = $34). 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 prophylaxis-adult provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - mandibular (D5120) and complete 
denture - maxillary (D5110) provided on November 1, 2021. 
 
You asked the Plan to pay for the dentures. The Plan denied your request. The Plan says dentures are not 
covered under your dental benefit 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 complete 
denture - mandibular (D5120) and complete denture - maxillary (D5110) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2332 x2) provided on 
August 23, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you needed these fillings done. You 
also say that you were told you have $1,000 annual dental claim coverage and would like these services to be 
covered. The Plan denied your request. The Plan says this is not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
resin-based composites (D2332 x2) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on April 8, 2021. 
 
You asked the Plan to pay for the complete series of radiographic images. You say that you would like for the 
Plan to cover this service. The Plan denied your request. The Plan says the denial of for this service is correct, 
because a complete series of radiographic images is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete series of radiographic images (D0210) provided on April 8, 2021.