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

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on 
December 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service provided in this case is not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided 
on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested foot orthotics are a medical 
necessity for you. The Plan denied your request. The Plan says the requested foot orthotics are not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a consultation (D9310) and partial denture (D5820) 
provided on November 4, 2021. 
 
You asked the Plan to pay more for a consultation and a partial denture. You say that you would like the Plan 
to pay more for the services that were rendered. The Plan denied your request. The Plan says the claim for the 
dentures processed correctly and the consultation remains denied as a non-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 Plan is only obligated to pay 50% 
of the allowed amount for dentures from an out-of-network provider. You are also responsible for the 
difference between the out-of-network providers charges and the Plans payment. In addition, the Plan is not 
obligated to pay for any service not listed as a covered benefit. Therefore, we decided that the Plan does not 
have to pay more for a consultation (D9310) and partial denture (D5820) provided on November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 31 physical therapy visits 
 
You asked the Plan to pre-approve therapy visits. You say that you had a brain injury and need additional 
physical therapy. The Plan denied your request. The Plan says you are receiving maintenance therapy services 
that can be performed at home. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee can become competent in brace instruction/use and a 
home exercise program with the already approved therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 31 physical therapy visits
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (G0151), occupational 
therapy (OT) services (G0152), services of clinical social worker (G0155), direct skilled nursing services of a 
registered nurse (RN) (G0299), and direct skilled nursing services of a licensed practical nurse (LPN) (G0300) 
provided from September 12, 2021, to October 11, 2021. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the 
medical records submitted do not meet criteria for reimbursement. The Plan also says the Plan of Care must be 
signed and dated by a physician before the claim for each episode of services is submitted for the final 
percentage payment. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs may not submit the claim until after all 
services are provided for the period and the physician has signed the plan of care and any subsequent verbal 
order.  
We looked at the file and Medicare rules. The provided documentation does not include a signed and dated 
Plan of Care. Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy 
(PT) services (G0151), occupational therapy (OT) services (G0152), services of clinical social worker (G0155), 
direct skilled nursing services of a registered nurse (RN) (G0299), and direct skilled nursing services of a 
licensed practical nurse (LPN) (G0300) provided from September 12, 2021, to October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coping (D2975) provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. 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 
coping (D2975) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the patient's doctor sent this specimen to your lab 
for processing so this should be covered. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 Neither the provider of service nor the referring provider in this case is a network provider with the Plan. The 
Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay 
for these items/services. Therefore, we decided that the Plan does not have to pay for lab services provided on 
March 24, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical stent (D5982), therapeutic parenteral drugs 
(D9612), and deep sedation/general anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the surgical stent, therapeutic parenteral drugs, and deep sedation/general 
anesthesia. You say that you never received any information about your dental coverage, and you were referred 
to an oral surgeon by your dentist. You also say that you need an implant in the front of your 
mouth. 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 pre-approve a 
surgical stent (D5982), therapeutic parenteral drugs (D9612), and deep sedation/general anesthesia (D9222 and 
D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial dentures (D5213) and mandibular 
partial dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that getting new dentures is medically 
necessary. 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 date of service March 22, 2018. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial dentures (D5213) and 
mandibular partial dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you and the dentist should have been made 
aware of status changes prior to your visit. You also say that you do not believe the Evidence of Coverage 
states it is your responsibility to check whether a doctor is in-network for each consecutive visit. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 19, 2022 by an out-
of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services on March 11, 
2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that the copay is too high 
and would like reimbursement. The Plan denied your request. The Plan says the cost-sharing you are being 
charged 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 a $0-
$250 facility copay per visit for each Medicare-covered outpatient hospital service. We cover medically 
necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or 
injury. Covered services include but are not limited to services in an emergency department or outpatient clinic, 
such as observation services or outpatient surgery. 
 
 
 You have been asked to pay a $250 copayment for outpatient hospital services. Outpatient hospital services 
falls within the Outpatient hospital 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 outpatient hospital services on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and local 
anesthesia (D9215), provided by a participating provider on October 7, 2021, to October 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a regular cleaning on July 21, 2020. 
You say that this should be covered. The Plan denied your request. The Plan says your benefit for D4341 has 
already been exhausted. The Plan says that D9215 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, certain limitations apply. The record 
shows your benefit for D4341 was exhausted on date of service July 21, 2020. Therefore, we decided that the 
Plan does not have to pay for periodontal scaling and root planing (D4341) and local anesthesia (D9215), 
provided by a participating provider on October 7, 2021, to October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve interstitial radiation source application, complex, includes 
supervision, handling, loading of radiation source, when performed (CPT code 77778) and stereotactic body 
radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course 
not to exceed 5 fractions (77373). 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs the radiation therapy in order 
for them to get better and start the therapy as soon as possible. The Plan denied your request. The Plan says that 
your request is not medically necessary because the enrollee's records show they do not have low- to 
intermediate-risk prostate cancer. 
 
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 services. Our physician reviewer 
found the services are medically necessary in this case. Combination external beam radiotherapy (SBRT) and 
brachytherapy along with neoadjuvant androgen deprivation is considered to be the standard of care for high 
risk localized prostate cancer. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve interstitial radiation source application, complex, includes supervision, handling, loading of radiation 
source, when performed (CPT code 77778) and stereotactic body radiation therapy, treatment delivery, per 
fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions (77373).  
 
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 pre-approve bone graft at time of implant placement (CPT code 
D9430), abutment supported porcelain/ceramic crown (D6058), prefabricated abutment - includes modification 
and placement (D6056) and surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs to have molars to chew 
food better. You state area #3 and #30 will be restored with dental implants. The Plan denied your request. The 
Plan says the services are not a covered benefit under 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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve bone graft at 
time of implant placement (CPT code D9430), abutment supported porcelain/ceramic crown (D6058), prefabricated abutment - includes modification and placement (D6056) and surgical placement of implant 
body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7241) provided by a 
participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the requested dental service 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 the 
removal of impacted tooth (D7241) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120), provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you were told that this would be covered. 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 a 
complete maxillary denture (D5110) and a complete mandibular denture (D5120), provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and oral/facial photographic 
images (D0350 x 4) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for a panoramic x-ray has already been exhausted. The Plan 
also says that oral/facial photographic images 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 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 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) and oral/facial 
photographic images (D0350 x 4) provided on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima 500MG/50ML vial. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this therapy would not be considered medically accepted in this enrollee's case. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of interstitial lung disease of undetermined etiology. 
The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Truxima 500MG/50ML vial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that based on the enrollee's condition my 
strong recommendation is that LTACH is the most appropriate level of care. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an 
LTACH. 
 
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 was admitted with acute hypoxic respiratory failure in the setting of 
sepsis and acute kidney injury.  The record indicates that the enrollee continues to have gastrointestinal 
bleeding and abnormal chest x-ray findings and requires ongoing acute care services. The enrollee continues to 
receive acute care services and these have not been denied.  The medical record does not indicate that the 
enrollee requires services not currently receiving but that would be available at the LTACH 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 the LTACH services.