Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from April 15, 2021, to April 20, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. The Plan denied your request. The Plan says that 
the claim failed to meet the contractual agreement of timely submission of 120 days. 
 
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. We found that the only denial reason given by the Plan was that the claim was 
filed past the timely filing limit. This is not correct based on the Medicare rules. No valid denial reason was 
provided by the Plan. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided 
from April 15, 2021, to April 20, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported crown (D6058) provided on September 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of the denial until November 
24, 2021. You also say that these services were needed due to your facial injury in 2019.  The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered service. The 
Plan says that abutment supported crown is not listed as a covered service either. 
 
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 custom fabricated abutment and 
abutment supported crown are not among those covered under this benefit. Additionally, the services you are 
asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the 
structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and 
abutment supported crown (D6058) provided on September 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical trays (A4550) and surgical supplies (A4649) 
provided on November 11, 2021. 
 
You asked the Plan to pay for codes A4550 and A4649. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Code A4550 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to.  
 
We find that code A4649 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to.  
 
Therefore, we decided that the Plan does not have to pay for the surgical trays (A4550) and surgical supplies 
(A4649) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #'s 3, 4, 8, 13, and 14 and 
retainer crowns (D6740) for tooth #'s 2, 5, 7, 9, 12, and 15. 
 
You asked the Plan to pre-approve pontics and retainer crowns. You say that you need something to be 
approved so you can eat. The Plan denied your request. The Plan says pontics (D6245) are not covered under 
your benefit plan. The Plan also says that a bridge is only allowed if you are missing one front tooth. 
 
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 pontics and 
retainer crowns 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 pontics and retainer crowns. Our 
reviewer says that the criteria for a fixed bridge is not met and no necessity has been found for a fixed bridge as 
requested. Our physician reviewer found in this instance, the request has been made for a bridge from tooth #9 
to 13, replacing tooth #'s 10, 11, and 12. You were missing tooth #'s 10 and 11 in the anterior segment and 
tooth #12 posterior tooth in the segment as well. Our reviewer found that the Plan provisions allows for 
replacement of a single anterior tooth where there are no missing posterior teeth. Our physician reviewer also 
found that in this case there are two anterior missing teeth as well as a missing posterior tooth. 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pontics (D6245) for tooth #'s 3, 4, 8, 13, and 14 and retainer crowns (D6740) 
for tooth #'s 2, 5, 7, 9, 12, and 15.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services (G0156), and home health 
skilled nursing services (G0299). 
 
You asked the Plan to pre-approve the home health PT and skilled nursing services. You say that the enrollee 
needs these services. The Plan denied your request. The Plan says the home health services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health aide and skilled 
nursing services. Our reviewer says that the home health aide and skilled nursing services are not medically 
necessary. Our physician reviewer found the documentation does not support that the enrollee was participating 
in home health before January 25, 2022 with a physician's signed orders. The reviewer found that the enrollee 
was most recently in an assisted living facility for custodial care.  The reviewer found that the enrollee 
remained medically stable. Therefore, the reviewer found that the requested home health services 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 home health aide and skilled nursing services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve home health aide services (G0156), and home health 
skilled nursing services (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted nervous system procedure provided on June 21, 
2021, billed with code 64999-26. 
 
You asked the Plan to pay for the procedure as billed. You say that this should be paid. The Plan denied your 
request. The Plan says this was billed with an invalid modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 64999 has a Pro/Tech flag of "0" in the Medicare Physician Fee Schedule. This means that the code 
describes physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 and TC cannot be used with these codes. Since modifier -
26 was used, this code is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of the procedure as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the unlisted nervous system procedure provided on June 21, 2021, billed with code 64999-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve a denture. You say that you were never able to use the previous partial 
denture you received, and the provider refused to fix it or take it back at that time. You also need a new denture 
to replace additional teeth at this time. The Plan denied your request. The Plan says you previously received a 
covered partial upper denture (D5213) on March 15, 2020. This service is covered once every five years, so the 
requested denture exceeds the frequency limitation of your 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. The Plan can cover one partial 
upper denture (D5213) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5213).   
Your complaint about the services previously provided by a Plan-contracted provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canals (D3330), posts and cores (D2954) and 
crowns (D2751) for teeth #18 and #19. 
 
You asked the Plan to pre-approve the dental services. 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 root 
canals (D3330), posts and cores (D2954) and crowns (D2751) for teeth #18 and #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided July 23, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that you were in a lot of pain and needed to go to 
an OON oral surgeon to have your tooth extracted immediately. The Plan denied your request. The Plan says 
this service is not covered because it was provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the surgical 
extraction when the services are provided in-network.  
 
We looked at the file and Medicare rules. In this case the extraction was provided OON. Based on this information, we decided that the Plan's rules for coverage of the surgical extraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided November 16, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you would like these x-rays covered. 
The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the complete 
series of x-rays, panoramic x-ray or vertical bitewing x-rays once every 36 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray 
was previously covered on August 2, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the intraoral - complete series of radiographic images (D0210) provided November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided December 1, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive exam and complete series of x-rays. You say that you would 
like the Plan to cover the services. The Plan denied your request. The Plan says these services are not covered 
when provided OON.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
comprehensive exam and complete series of x-rays when the services are provided in-network. 
 
We looked at the file and Medicare rules. 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. We 
found no exception that would require the Plan to pay for these items/services. Based on this information, we 
decided that the Plan's rules for coverage of the comprehensive exam and complete series of x-rays have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new 
or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided 
December 1, 2021, 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 comprehensive oral evaluation - new or established 
patient (D0150), prophylaxis - adult (D1110), intraoral - complete series of radiographic images (D0210), 
endodontic therapy, anterior tooth (excluding final restoration) (D3310), crown - porcelain fused to high noble 
metal (D2750), and the prefabricated post and core in addition to crown (D2954) provided April 13 2021, to 
August 19, 2021, by an out-of-network (OON) provider.  
You asked the Plan to pay for the comprehensive oral exam, dental cleaning, complete series of x=rays, root 
canal, crown and prefabricated post and core. You say that you would like these services covered. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan states that services 
obtained from provider outside the Plans dental vendors network are not covered. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the comprehensive oral exam, dental cleaning, complete series of x=rays, root canal, crown and prefabricated 
post and core have not been met. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation - new or established patient (D0150), prophylaxis - adult (D1110), intraoral - 
complete series of radiographic images (D0210), endodontic therapy, anterior tooth (excluding final 
restoration) (D3310), crown - porcelain fused to high noble metal (D2750), and the prefabricated post and core 
in addition to crown (D2954) provided April 13 2021, to August 19, 2021, 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 bone replacement graft for ridge preservation - per site 
(D7953), guided tissue regeneration - resorbable barrier, per site (D4266), biologic materials to aid in soft and 
osseous tissue regeneration (D4265), unspecified adjunctive procedure, by report (D9999), localized delivery 
of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), and 
re-evaluation - limited, problem focused (established patient; not post-operative visit) (D0170) provided May 
27, 2021 to November 2, 2021. 
 
You asked the Plan to pay for the bone replacement graft, guided tissue regeneration, biologic materials to aid 
in soft and osseous tissue regeneration, unspecified adjunctive procedure, localized delivery of antimicrobial 
agents, and re-evaluation - limited, problem focused. You say that you would like these services to be covered. 
The Plan denied your request. The Plan says these services 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 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 bone 
replacement graft for ridge preservation - per site (D7953), guided tissue regeneration - resorbable barrier, per 
site (D4266), biologic materials to aid in soft and osseous tissue regeneration (D4265), unspecified adjunctive 
procedure, by report (D9999), localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue, per tooth (D4381), and re-evaluation - limited, problem focused (established patient; 
not post-operative visit) (D0170) provided May 27, 2021 to November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facility charges and anesthesia (41899, 00170) for the 
surgical extraction of multiple teeth for carious disease (cavities). 
 
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 the requested services are dental in nature, which means that they are 
not covered by Medicare or by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
facility charges and anesthesia (41899, 00170) for the surgical extraction of multiple teeth for carious disease 
(cavities).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5820). 
 
You asked the Plan to pre-approve the denture. You say that this denture is necessary. The Plan denied your 
request. The Plan says this type of denture is 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 an 
interim partial denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that your previous dentures do not work, and 
they are too small. The Plan denied your request. The Plan says you previously received a complete upper 
denture and complete lower denture on March 27, 2019, and these services were covered by the Plan at that 
time. Your benefit covers dentures once every five years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan can cover one 
complete upper denture every five plan years, and one complete lower denture every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve complete upper and lower dentures (D5110, D5120).