Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health care visit provided on October 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health care visit. You say that the facility should have requested the 
authorization for service and the treatment provided was out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider with no prior approved 
authorization for services rendered. Also, services rendered was not urgent or emergent. 
 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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health care visit provided on October 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 additional PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
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 10 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You should be 
able to transition to an independent home exercise program with the already approved therapy. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), intraoral x-ray (D0220) and 
bitewing x-rays (D0270) provided on September 23, 2021. 
 
You asked the Plan to pay for the dental exam and x-rays. You say that these services were necessary, and you 
were not told in advance that you would be responsible for these charges. The Plan denied your request. The 
Plan says the limited oral exam is not a covered service under your dental benefit. The intraoral x-ray and 
bitewing x-rays are covered services, but you have exceeded the frequency limitations for these x-rays in 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover 
services which are not listed in the Plan's dental benefits chart section of the contract. The Plan can cover one intraoral x-ray per calendar year and one set of bitewing x-rays per calendar year. 
 
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 or were requested in a frequency that exceeds what is covered under 
this benefit. Documentation shows that you had a previous set of bitewing x-rays and a previous intraoral x-ray 
provided and covered by the Plan in March 2021. Therefore, we decided that the Plan does not have to pay for 
the limited oral exam (D0140), intraoral x-ray (D0220) and bitewing x-rays (D0270) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) provided on 
October 6, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that this service was necessary 
and feel it should be at least partially paid, as the Plan covers similar services. The Plan denied your request. 
The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
comprehensive periodontal exam (D0180) provided on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (aducanumab) treatments. 
 
You asked the Plan to pre-approve the Aduhelm treatments. You say that it is felt that this treatment would 
benefit the enrollee. The Plan denied your request. The Plan says the coverage criteria for this drug have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aduhelm treatments. Our reviewer 
says that the requested treatment is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of late onset Alzheimer's disease 
and increasing alcohol use.  The record indicates that the enrollee has moderate cognitive impairment with a 
Montreal Cognitive Assessment score of 13.  The record provided does not support a diagnosis of mild 
dementia or mild cognitive impairment in presence of a diagnosis of Alzheimer's disease.  
 
The Food and Drug Administration 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.  
 
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 Aduhelm treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Aduhelm (aducanumab) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) provided on March 16, 2021, and 
the resin-based filling (D2393) provided on April 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could see this provider. 
The Plan denied your request. The Plan says they have agreed to make a one-time exception and pay for your 
exam. However, the x-ray and filling remain denied as these services are not covered by your dental benefit, 
regardless of the network status of the provider. 
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 the 
intraoral x-ray (D0220) provided on March 16, 2021, and the resin-based filling (D2393) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided August 19, 2021. 
 
You asked the Plan to pay for the chiropractic visit. You say that you stopped seeing this doctor because he was 
hurting you. You now pay out of pocket for your care. The Plan denied your request. The Plan says this service 
is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) provided August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), an 
implant supported porcelain/ceramic crown (D6065) and a prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve a surgical placement of an implant body, an implant supported 
porcelain/ceramic crown and a prefabricated abutment. You say that the enrollee does not tolerate dentures and 
he is not able to chew his food correctly. The Plan denied your request. The Plan says the requested services 
are not covered under your benefit Plan. 
 
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 pre-approve a 
surgical placement of an implant body (D6010), an implant supported porcelain/ceramic crown (D6065) and a 
prefabricated abutment (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware 
that a consultation visit was only allowed once per year. You also say that you are on a fixed income and 
cannot afford to pay any more. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on October 21, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on October 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that 
assistance with transfers can safely be administered at home via home health care services until the enrollee is 
able to be fitted for prosthesis. The patient does not require inpatient skilled nursing. 
 
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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
intraoral - periapical first radiographic image (D0220), and pulp cap - direct (excluding final restoration) 
(D3110) provided November 20, 2021. 
 
You asked the Plan to pay for the core buildup, intraoral x-ray and pulp cap. You say that you were told all 
dental services would be covered up to your $2,000 allowance. The Plan denied your request. The Plan says 
you have exceeded the frequency limit for the x-ray and the remaining services are not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the intraoral 
x-ray once per calendar year.  
We looked at the file and Medicare rules. The Plan provided documentation showing that an intraoral x-ray 
was previously covered on November 11, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the intraoral x-ray has been exceeded. Though the Plan offers dental benefits in 
excess of Medicare coverage, the core buildup and pulp cap are not among those covered services. Therefore, 
we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
intraoral - periapical first radiographic image (D0220), and pulp cap - direct (excluding final restoration) 
(D3110) provided November 20, 2021.  
 
Your complaint about potentially receiving misinformation about your benefits not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), and periapical x-rays (D0220, D0230) provided on November 16, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you only have 2 teeth. 
You say that you did not ask for all the extras. You also say that you only asked for a cleaning and routine 
check up. The Plan denied your request. The Plan says the provider in this case does not participate with your 
Dental plan. The Plan also says that nonparticipating providers can bill you for additional costs if what they 
charge is more than the maximum payable benefit amount for preventive services covered by 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 and the services are listed as covered, 
nonparticipating providers can bill you for additional costs if what they charge is more than the maximum 
payable benefit amount for preventive services covered by the plan. Therefore, we decided that the Plan does 
not have to pay an additional amount for the oral exam (D0120), prophylaxis (D1110), and periapical x-rays 
(D0220, D0230) provided on November 16, 2021.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 records show that the enrollee's rehab needs can be met safely at a lower intensity 
and alternate setting such as in a Skilled Nursing 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 3, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you have not had any oral evaluations 
prior to the one with this provider. You also say that the nitrous oxide was necessary as you have severe 
anxiety that would make it very difficult to complete the extraction procedure. The Plan denied your request. 
The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 
been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on September 29, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and drugs or 
medicaments dispensed in the office for home use (D9630 x 2) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that the treatment you received was to help in 
relieving and correcting your gum disease. You also say that you cannot pay for all of this by yourself. The 
Plan denied your request. The Plan says gingival irrigation is not a covered service. The Plan says drugs or 
medicaments dispensed in the office for home use is not a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation and drugs or 
medicaments dispensed in the office for home use are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and drugs or medicaments 
dispensed in the office for home use (D9630 x 2) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve bone replacement grafts. You say that you are in pain and cannot get your 
teeth extracted until you get this bone graft. The Plan denied your request. The Plan says this service is not 
covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve bone 
replacement grafts for ridge preservation - per site (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
July 6, 2021. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you have provided medical 
records to justify payment for these services. The Plan denied your request. The Plan says payment for these 
codes is bundled into other codes.  The Plan says that it has overturned its initial denial of code 00300 billed for 
this date of service. 
 
  The Plan must follow Medicare rules. Medicare rules say that for procedure codes with a status indicator of B 
on the Medicare Physician Fee Schedule Database, payment for these services is always bundled into payment 
for other services.  No separate payment is ever made for these codes. Both procedure codes 99100 and 99104 
have a status indicator of B on the Medicare Physician Fee Schedule Database, so neither of these codes is 
separately payable. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date 
of service July 6, 2021.