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

 
We decided that the Plan does not have to pre-approve dental care to be provided by the dentist you saw prior 
to enrolling in this plan. 
 
You asked the Plan to pre-approve dental care with your preferred dental provider. You say that you have seen 
this dentist for many years and would like to continue to see them for your care. The Plan denied your request. 
The Plan says dental services are only covered when performed by your Plan-assigned dental provider. The 
provider in this case is not part of the Plan's in-network dental group and therefore cannot be assigned as your 
dental 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. The Plan requires services to 
be provided by an assigned network dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a 
provider who is not part of the Plan's network and is not your assigned dental provider are not covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve dental care to be provided by the 
dentist you saw prior to enrolling in this plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary. 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 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 
biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on December 2, 2021. 
 
You asked the Plan to pay for the panoramic x-ray. You say that since your insurance covers bitewing x-rays, 
you believe the insurance company should pay the cost that they would have paid if this were a bitewing x-ray. 
The Plan denied your request. The Plan says this is not a covered service under your 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 
panoramic x-ray (D0330) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), two 
periodontal scalings and root planings (D4342 x2), and two gingival irrigations (D4921 x2) provided on 
November 12, 2021. 
 
You asked the Plan to pay for the topical application of fluoride varnish, scalings and planings, and gingival 
irrigations. You say that you were not advised by the dentist that these services would not be covered. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan 
also says that when you contacted the Plan prior to this date of service, no inaccurate information was 
provided. 
 
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 
topical application of fluoride varnish (D1206), two periodontal scalings and root planings (D4342 x2), and 
two gingival irrigations (D4921 x2) provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasties without extractions (D7320 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says alveoloplasties without extractions are not listed as covered services. 
 
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 alveoloplasties without 
extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve alveoloplasties without extractions (D7320 x 2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test (93017) provided on December 
6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cardiovascular stress test. You say that you would like this claim to be 
reprocessed for medical necessity. The Plan denied your request. The Plan says the treating provider is not a 
network provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 
approved in advance. 
 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 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 the cardiovascular stress test (93017) provided on 
December 6, 2021 by an out-of-network (OON) provider.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. There are no services at 
the LTACH that the enrollee requires that are not already available and covered 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 pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment  includes placement (D6057), abutment supported porcelain fused to 
metal crown (noble metal) (D6061), and bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve endosteal implant, custom fabricated abutment, abutment supported crown 
and bone replacement graft. You say that you would like these services covered. The Plan denied your request. 
The Plan says these 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 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 surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment  includes 
placement (D6057), abutment supported porcelain fused to metal crown (noble metal) (D6061), and bone 
replacement graft for ridge preservation - per site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second transcutaneous electrical nerve stimulation (tens) 
device (E0730) provided on November 2, 2021. You asked the Plan to pay for a second tens device. You say that this is supported in the records. The Plan 
denied your request. The Plan says this exceeds the MUE for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 1. The MAI value for this code is 2. You billed 2 units of this code, the 
first of which was previously paid, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of a second tens device have not been met. Therefore, we decided that the Plan does not 
have to pay for a second transcutaneous electrical nerve stimulation (tens) device (E0730) provided on 
November 2, 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 this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 this enrollee with right knee osteoarthritis does not meet the coverage criteria for an 
IRF admission. On a review of the available records, the enrollee is medically stable, and does not need physician close 
supervision three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented in the 
record. At the current functional level, the enrollee does not need 3 hours a day five days a week of IRF 
therapies with interdisciplinary management and the rehab needs can be met in an alternate and lower setting 
such as in an assisted living facility with therapies as needed. IRF admission is not medically necessary based 
on medical stability, lack of medical complexity, and lack of rehab nursing needs and current functional level. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from December 3, 2021, to December 6, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that they will not let you bring your own 
drugs to the hospital. You also say that you should not be liable for this bill. The Plan denied your request. The Plan says the cost of the drugs you got during your visit are not covered under your medical coverage. The 
Plan also says you may ask for them to be covered under your prescription drug coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from December 3, 2021, to December 6, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 5, 2022. 
 
You asked the Plan to pay for the crown. You say that you paid your January 2022 premium, the check was 
cashed, and you do not understand why this service is not covered. You also say that you did not receive any 
notification that your dental rider had been cancelled. The Plan denied your request. The Plan says this service 
is not covered. 
 
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. The Plan says that you disenrolled from the Plan, with coverage 
ending December 31, 2021, and then re-enrolled in the medical plan, but did not include enrollment for the 
Optional Supplemental Dental plan effective January 1, 2022. Therefore, we decided that the Plan does not 
have to pay for the crown (D2740) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), topical application of fluoride varnish (D1206), periodontal maintenance (D4910), and resin-based 
composite (D2392) provided on October 18, 2021, and December 20, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, topical application of 
fluoride varnish, periodontal maintenance, and resin-based composite. You say that according to the Plan 
information, you had a $50 copay for dental services. You also say that though the representative you spoke 
with said you did not have dental coverage according to the Plan information, you did have coverage. The Plan 
denied your request. The Plan says you do not have routine dental benefits for the 2021 plan year. The Plan 
also says that you were not enrolled into any optional supplemental benefits for the 2021 plan year. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150), panoramic x-ray (D0330), topical application of fluoride varnish (D1206), periodontal 
maintenance (D4910), and resin-based composite (D2392) provided on October 18, 2021, and December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) or pay more for the 
inhalation of nitrous oxide/analgesia (D9230) provided on November 10, 2021. 
 
You asked the Plan to pay for the preventive procedure and to pay more for the inhalation of nitrous 
oxide/analgesia. You say that you would like to be reimbursed for the charges for the personal protective 
equipment that you had no control over. The Plan denied your request. The Plan says your $2,000 calendar year 
maximum has been met. 
 
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 Plan offers a $2,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the November 10, 2021 date of service and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999) or pay more for the inhalation of nitrous oxide/analgesia (D9230) provided on 
November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on January 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - 
new or established patient (D0150), bitewings - four radiographic images (D0274), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and 
prophylaxis - adult (D1110) provided July 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the comprehensive oral exam, bitewing x-rays, intraoral 
x-rays and dental cleaning. You say that you were told the dentist is in-network and your dentist indicated that 
the services are being billed with the wrong name. The Plan denied your request. The Plan says intraoral x-rays 
are not covered under your benefits. The remaining services were processed correctly according to your OON 
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 Plan covers the 
comprehensive oral exam, bitewing x-rays and dental cleaning with 50% coinsurance when provided OON. 
You may be billed by the OON provider for any amount grater than the payment made by the Plan to the 
provider. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that they covered 50% of 
the allowed amount for the comprehensive oral exam, bitewing x-rays and dental cleaning. These services were 
provided OON. This means that the services were correctly covered by the Plan, and you are responsible for 
the remaining amount. Though the Plan offers dental benefits in excess of Medicare coverage, the intraoral x-
rays are not among those covered services. Therefore, we decided that the Plan does not have to provide 
additional payment for the comprehensive oral evaluation - new or established patient (D0150), bitewings - 
four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), intraoral - periapical 
each additional radiographic image (D0230), and prophylaxis - adult (D1110) provided July 22, 2021, by an 
out-of-network (OON) provider.  
 
Your complaint about potentially provided misinformation from a Plan representative is 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening testing (82728, 83036, 84480, 87633) provided on 
August 5, 2020. 
 
You asked the Plan to pay for screening testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening 
testing (82728, 83036, 84480, 87633) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6010, D0367, D6070, D6241). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are either not covered or do not meet clinical criteria. 
 
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 services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested dental services are not medically reasonable or necessary. Our physician reviewer found a review of 
the documentation indicates that D0367 (Cone Beam Scan) was denied due to frequency; scan was covered 6 
months ago. The remaining services, D6010,D6070 and D6241, are beyond the scope of the plan - not covered 
expenses as noted in the Explanation of Benefits (EOB). The documentation does not support the criteria for 
coverage for the services indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D6010, D0367, D6070, D6241).