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

 
We decided that the Plan does not have to pay for core build up (D2950 x 2) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says core build up (D2950) is 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 core build 
up (D2950 x 2) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210), incisions and drainages of 
abscesses (D7510), non-intravenous conscious sedation (D9248), and drugs or medicaments dispensed in the 
office for home use (D9630) provided on March 2, 2022. 
 
You asked the Plan to pay for the surgical extractions, incisions and drainages of abscesses, non-intravenous 
conscious sedation, and drugs or medicaments. You say that you would like to appeal these services. 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 
surgical extractions (D7210), incisions and drainages of abscesses (D7510), non-intravenous conscious 
sedation (D9248), and drugs or medicaments dispensed in the office for home use (D9630) provided on March 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on March 16, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you had a periodontal 
evaluation on September 23, 2021, and another one on March 16, 2022. You also say that you paid out of 
pocket for the evaluation on September 23, 2021, and no claim was paid by the Plan. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted for the time 
period. 
 
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 February 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) 
provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #2 (D2751) provided on April 4, 2022. 
 
You asked the Plan to pay for a crown. You say that crowns should be covered at 25%. The Plan denied your 
request. The Plan says a crown (D2751) is not covered by your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
on tooth #2 (D2751) provided on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for resin-based composite fillings (D2392, D2332, D2331) provided on 
February 22, 2022. 
 
You asked the Plan to pay for fillings. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says that your benefit for fillings has been exhausted. 
 
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 fillings has been 
exhausted. Therefore, we decided that the Plan has to pay for resin-based composite fillings (D2392, D2332, 
D2331) provided on February 22, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Psoriasis vulgaris. He 
has not tried and failed the Plan's required drugs, Remicade, Inflectra, or Infliximab and Stelara. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Ilumya is not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a resin-based composite filling on tooth #14 (D2393) provided on 
February 3, 2022. 
 
You asked the Plan to pay for a filling. You say that you disagree with the processing of this claim. The Plan 
denied your request. The Plan says that the claim was paid on the least costly method of treatment. 
 
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 medical records for our physician to review. Without 
the medical records we are unable to determine if the less expensive alternate treatment would produce a 
professionally satisfactory result. Therefore, we decided that the Plan has to pay for a resin-based composite 
filling on tooth #14 (D2393) provided on February 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 an additional periapical x-ray (D0230) provided on March 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only had one x-ray this year. 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 March 11, 2022. 
Therefore, we decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided 
on March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional oxygen supplies. 
 
You asked the Plan to pre-approve the requested items. You say that it is important to have a backup when 
away from home. The Plan denied your request. The Plan says backup equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 The file shows that an additional battery and/or oxygen tanks were requested. These items serve the same 
purpose as the requested items. Therefore, we decided that the Plan does not have to pre-approve additional 
oxygen supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #6 (D2332) provided 
on April 7, 2022. 
 
You asked the Plan to pay for a filling. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says resin-based composite fillings (D2332) are not covered by your routine 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite filling on tooth #6 (D2332) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp cap on tooth #28 (D3120) provided on February 24, 2022. 
 
You asked the Plan to pay for pulp cap. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says pulp cap (D3120) is 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 pulp cap 
on tooth #28 (D3120) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from February 18, 2022, to 
February 25, 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 2D oral/facial photographic images (D0350), cone beam imaging 
(D0367), oral hygiene instructions (D1330), unspecified periodontal procedure (D4999), gingival irrigation 
(D4921), saliva sample (D0417), and an observation office visit (D9430) are not covered by your routine dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services provided from February 18, 2022, to February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural adhesiolysis (62264). 
 
You asked the Plan to pre-approve RACZ procedure. You say that you are request that the Plan do what is in 
the best interest for the enrollee and authorize a safer, more controlled, cost-effective procedure to help with his 
pain to make each day better for him. The Plan denied your request. The Plan says this procedure is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RACZ procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve lumbar epidural adhesiolysis (62264).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 14, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the enrollees annual allowance for comprehensive dental services has 
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, the requested items or services are not 
among those covered under this benefit when the annual allowance amount has been exhausted. Therefore, we 
decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair for use with a seat lift mechanism. 
 
You asked the Plan to pre-approve a chair for use with a seat lift mechanism. You say that the enrollee has 
trouble getting out of a chair. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that seat lift chairs are not covered. Coverage is 
limited to a seat lift mechanism.  
 
We looked at the file and Medicare rules. Although a seat lift chair may be appropriate, Medicare does not 
cover this item and the Plan must provide coverage only for items that Medicare covers. Based on this 
information, we decided that Medicare rules for coverage of a chair for use with a seat lift mechanism have not 
been met. 
 
  
 Therefore, we decided that the Plan does not have to pre-approve a chair for use with a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH is medically necessary. The 
Plan denied your request. The Plan says the medical criteria for a LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and requires only short-term 
additional acute care services that can safely be administered at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 
 
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) and pulp vitality test (D0460) 
provided on April 6, 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 cone beam imaging (D0364) and pulp vitality test (D0460) are not 
covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam imaging (D0364) and pulp vitality test (D0460) provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the in-network provider does not do strabismus surgery. The Plan denied your request. 
The Plan says as a Plan member, you may obtain pre-authorization to a non-network provider if there are no 
network providers with appropriate training and experience to meet your particular health care needs. The Plan 
says that the Plans Medical Director has determined this service could be provided by a Plan participating 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee needs to keep their 
dialysis appointments, which is three times a week, and they cannot afford to rent a van for $600.00 a week. 
The Plan denied your request. The Plan says the benefit limit of 48 one-way rides has been reached, and 
additional coverage outside of this benefit limit is unable to be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880).  
 
You asked the Plan to pre-approve the device. You say that the device should be approved under your medical 
benefit.  The Plan denied your request. The Plan says this item is considered a dental device and it is not 
covered to treat temporomandibular joint (TMJ) disorders. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal orthotic device (D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on March 30, 2022. 
 
You asked the Plan to pay for an extraction. You say that you feel this service should be covered. The Plan 
denied your request. The Plan says an extraction (D7140) is 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 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 an 
extraction (D7140) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a detailed oral evaluation (D0160) and does not have to pay 
more for an extraction (D7210) provided on January 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware the provider was out-
of-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plan's cost-sharing amount when your services are received from an out-of-network provider. The Plan also 
says that a detailed oral evaluation (D0160) is not covered by the Plan's 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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. A 
detailed oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for a detailed oral evaluation (D0160) and does not have to pay more for an extraction (D7210) 
provided on January 27, 2022.