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

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and intraoral 
x-rays (D0210) provided on April 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the processing of this 
claim. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) 
and intraoral x-rays (D0210) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the member was not enrolled at the time of the 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 6, 2020, to November 23, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the 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 pay for the dental 
services on November 6, 2020, to November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and lower partial 
denture (D5212) provided November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. 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 complete upper denture (D5110) and lower partial denture (D5212) provided November 15, 
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 a crown on tooth #18 (D2740), core build up on tooth #18 
(D2950), and endodontic therapy on tooth #18 (D3330) provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your benefits charged. 
The Plan denied your request. The Plan says that a crown (D2740), core build up (D2950), and endodontic 
therapy (D3330) are 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 #18 (D2740), core build up on tooth #18 (D2950), and endodontic therapy on tooth #18 (D3330) 
provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3348), a 
limited oral evaluation (D0140), and intraoral imaging (D0220), a cone beam CT capture (D0364), and pulp 
vitality tests (D0460), provided by an out-of-network provider on May 11, 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 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 retreatment of previous root canal therapy (D3348), a limited oral evaluation (D0140), and 
intraoral imaging (D0220), a cone beam CT capture (D0364), and pulp vitality tests (D0460), provided by an 
out-of-network provider on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental cone beam CT image (D0380) provided on June 22, 
2022. 
 
You asked the Plan to pay for the dental cone beam CT image. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
do not fall within 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 a dental 
cone beam CT image (D0380) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #27 (D2740) provided on January 10, 2022. 
 
You asked the Plan to pay for a crown. You say that you were advised crowns were covered at 50%. The Plan 
denied your request. The Plan says your annual maximum benefit has been met. 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 this benefit includes 
coverage up to a $2,000 annual maximum amount. The contract says that you are responsible for any amount 
above the coverage benefit limit. 
 
The record shows your annual maximum benefit has been met. You have been asked to pay $304 for a crown 
on tooth #27. This item/service falls within the dental 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 pay for a crown on tooth #27 (D2740) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided on June 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. You also 
say that they should be paid. The Plan denied your request. The Plan says gingival irrigation is not listed as a 
covered dental service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation (D4921 x 4) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have reimbursement for dental services provided on June 21, 2022. 
 
You asked the Plan reimbursement for the dental services. You say that you pay for additional monthly fee for 
services, and you expect to be reimbursed for the covered services. 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 
reimbursement for dental services provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the telescoping push handle (CPT code K0108 x2) and 
the travel cushion (E1399). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says these items or services do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The primary use of a travel cushion is outside the home and durable medical equipment is covered if the 
primary use is inside the home. Furthermore, telescoping push handles are for the convenience of the caretaker. 
You are able to control the wheelchair through push rim activated power assist. Therefore, we decided that the 
Plan does not have to pre-approve the telescoping push handle (CPT code K0108 x2) and the travel cushion 
(E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4341). 
 
You asked the Plan to pre-approve 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 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 12, 2022. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing in all 
four quadrants (D4341).
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 the enrollee requires close monitoring 
with daily physician management and prolonged and intensive skilled services. You say that the enrollee's 
medical needs cannot be adequately managed in his current condition at a skilled nursing facility. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care setting. 
 
 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment - includes placement 
(D6057) and a single crown restoration (D6058) for teeth #03, #05, #07, #10, #14, and #15. 
 
You asked the Plan to pre-approve a custom fabricated abutment - includes placement (D6057) and a single 
crown restoration (D6058) for teeth #03, #05, #07, #10, #14, and #15. You say that the member needs this done 
fast. The Plan denied your request. The Plan says these requested services are not covered under the member's 
health plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment - includes placement (D6057) and a single crown restoration (D6058) for teeth 
#03, #05, #07, #10, #14, and #15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that you need a hospital bed due to 
health issues. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a semi-
electric hospital bed. 
 The Plan follows Medicare rules. Medicare rules state that a semi-electric hospital bed is only covered if 
certain criteria are met. 
 
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 semi-electric hospital bed. Our reviewer 
says that you do not meet the Medicare criteria for a semi-electric hospital bed. Our physician reviewer found 
the documentation does not support that you have a condition that requires frequent positioning of the head and 
mattress to alleviate pain, promote good body alignment, prevent contractures, or avoid respiratory infections 
in a way that an ordinary bed is not able to. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery to be provided by an OON provider. 
 
You asked the Plan to pre-approve the surgery. You say that you are having difficulty finding a provider to do 
the procedure. The Plan denied your request. The Plan says we have several in-network facilities where this 
procedure can be done. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be provided by an OON provider.
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 provider told you that you needed a 
deep cleaning. The Plan denied your request. The Plan says that the requested service is not covered due to 
there being 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 the adequate radiographs that were used in making 
their decision. The Plan did not support 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: Favorable

 
We decided that the Plan has to pre-approve a dental crown (D2752) 
 
You asked the Plan to pre-approve the dental crown. You say that the services should be covered as you 
disagree with the denial and the crown is medically necessary. The Plan denied your request. The Plan says that 
the services denied correctly as you have exhausted your dental benefit for this service. 
 
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 failed to include documentation that explicitly shows the service D2752 
was provided in the last 60 months. Therefore, we decided that the Plan has to pre-approve a dental crown 
(D2752)  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and attendant control for 
a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature and attendant controller. You say that you are 
appealing this denial. The Plan denied your request. The Plan says a power seat elevation feature is not covered 
by Medicare and an attendant control is not covered if provided in addition to a beneficiary-operated drive 
control system. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered, and 
an attendant control is not covered if provided in addition to a beneficiary-operated drive control system.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature and attendant controller have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation feature and attendant control for a power 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you say that you never received your 
dentures in February 2020. 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 February 27, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts on tooth #20, 23, 26, and 29 
(D7953), endosteal implants on tooth #20, 23, 26, and 29 (D6010), a complete mandibular overdenture 
(D5865), and prefabricated abutments on tooth #20, 23, 26, and 29 (D6056). 
 
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 bone replacement grafts (D7953), endosteal implants (D6010), a 
complete mandibular overdenture (D5865), and prefabricated abutments (D6056) 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement grafts on tooth #20, 23, 26, and 29 (D7953), endosteal implants on tooth #20, 23, 26, and 29 (D6010), a complete mandibular overdenture (D5865), and prefabricated abutments on tooth #20, 23, 26, and 
29 (D6056).