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

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in all four quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that the deep cleaning is needed to maintain 
your gum health. The Plan denied your request. The Plan says that there is no evidence of significant bone loss. 
 
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 a clear copy of the medical records they used in their 
review. The Plan has not supported their decision to deny your request. Therefore, we decided that the Plan has 
to pre-approve periodontal scaling and root planing in all four quadrants (D4341).  
 
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 a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on dates of service June 3, 2021, and 
November 5, 2021. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper and 
lower right quadrants (D4342). 
 
You asked the Plan to pre-approve periodontal scaling. You say that you disagree with the denial of dental 
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 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 November 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in the 
upper and lower right quadrants (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #10 (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that your crown is broken, and you need a new 
one. 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 18, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #10 (D2750).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection procedure provided on February 10, 2022. 
 
You asked the Plan to pay for the injection procedure. You say that the diagnosis code is unrelated to the 
enrollee's hospice care. The Plan denied your request. The Plan says original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the injection procedure provided on February 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on February 
12, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were told you had to 
take an ambulance and you were told it would be covered. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $250 
copayment for each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services 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 to waive the copayment for ambulance transport 
provided on February 12, 2022.
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. You say that you are having blood pressures issues, are on oxygen 
and having dizzy spells. You say that your provider is requesting you have physical therapy. The Plan denied 
your request. The Plan says the services you need can safely be provided in other settings. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310), endodontic therapy, molar tooth (excluding final restoration) (D3330), and pulp vitality tests (D0460) 
provided March 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee was referred to this provider. The 
Plan denied your request. The Plan says the claims has been re-processed as in-network. However, the 
enrollees benefit for the periapical x-ray has already been exhausted, and the remaining services are not 
covered under his benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollees benefit for the requested item or service was exhausted on date of service March 7, 2022. 
The enrollees dental benefit does not include dental consultations, root canals or pulp vitality tests as covered 
services.  Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first 
radiographic image (D0220), consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310), endodontic therapy, molar tooth (excluding final restoration) (D3330), 
and pulp vitality tests (D0460) provided March 14, 2022.
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 there is no 
documentation to indicate the enrollee has completed their hospital treatment. 
 
  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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction on tooth #24 (D7111) provided on March 18, 
2022, and a retainer cast metal for resin bonded fixed prosthesis for tooth #24 (D6545) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an extraction (D7111) and retainer cast metal for resin bonded 
fixed prosthesis (D6545) 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 pay for an 
extraction on tooth #24 (D7111) provided on March 18, 2022, and a retainer cast metal for resin bonded fixed 
prosthesis for tooth #24 (D6545) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #19 and 30 (D6010). 
 
You asked the Plan to pre-approve implants. You say that you were under the impression the implants would 
be approved and you went through the proper process with the dentist. You also say that they did not want to 
have to remove dentures. The Plan denied your request. The Plan says a partial denture will adequately replace 
the missing teeth if the treatment meets criteria for partial 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 covers implants 
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 implants. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that tooth #19 has not been removed from the 
arch, and there is no clear indication as to why this would be necessary. In this instance, the placement of the 
missing teeth on opposite sides of the arch would allow for a partial denture to be used, which are commonly used in this type of circumstance.  Given that a partial denture could replace the teeth in question, implants 
would not be considered meeting Plan criteria in this case. 
 
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 implants have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endosteal implants on tooth #19 and 30 (D6010).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care services provided from February 1, 2020, 
to January 4, 2021. 
 
You asked the Plan to pay for the custodial care services. You say that you did not know the Plan was not 
paying for the room and board. You also say that you should not be responsible for the facility's billing 
mistake. The Plan denied your request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. The record shows that you signed a form acknowledging that care 
beginning on January 19, 2020, may not be covered. Based on this information, we decided that Medicare rules 
for coverage of the custodial care services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
custodial care services provided from February 1, 2020, to January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #13 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
serivces. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a crown on 
tooth #13 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the golf services purchased on January 1, 2021. 
 
You asked the Plan to reimburse you for the golf services. You say that people were getting sick at indoor 
facilities, and you feel you should be reimbursed because golf is outdoors and close to your home. The Plan 
denied your request. The Plan says golf is not covered under the Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for qualified programs. 
 
The Plans rules for coverage of gym benefits have not been met because golf is not covered under the 
Wellness Allowance benefit. Therefore, we decided that the Plan does not have to reimburse you for the golf 
services purchased on January 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root cleaning in the upper right quadrant, 
lower right quadrant, and lower left quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that you need this service because you have 
pockets in your gums. The Plan denied your request. The Plan says that there is no evidence of significant bone 
loss. 
 
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 a clear copy of the medical records they used in their 
review. The Plan has not supported their decision to deny your request. Therefore, we decided that the Plan has 
to pre-approve periodontal scaling and root cleaning in the upper right quadrant, lower right quadrant, and 
lower left quadrant (D4341).  
 
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: 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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 document does not support the medical necessity for admission to an IRF. While the enrollee may benefit from continued PT and OT, the enrollee's rehab needs can be safely provided in a lower 
intensity and alternate setting such as in an SNF. 
 
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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture 
after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on March 15, 2022, and 
April 13, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you never had these copayments 
before, and you cannot afford them. The Plan denied your request. The Plan says the copayments applied are 
correct. 
 
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 $250 
copayment for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. 
 
 
 
 You have been asked to pay $500 ($250 x 2 visits) copayment for injections. Injections fall within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 to waive the copayment for injections provided on 
March 15, 2022, and April 13, 2022.