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

 
We decided that the Plan has to pay for an arch upgrade-upper zirconia provided on January 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have provided all correct codes, all charges 
for the codes and signed all paperwork appropriately. You say you had this work done because your entire 
upper implant, which is over ten years old, began to deteriorate and several teeth were breaking. The Plan 
denied your request. The Plan says that the necessary documentation to process this request correctly was never 
received. 
 
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. We find that there is enough information in the case file and the additional 
information we received to determine what services were provided. Therefore, we decided that the Plan has to 
pay for an arch upgrade-upper zirconia provided on January 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for open treatment and/or reduction of vertebral fracture(s) and/or 
dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical rendered on September 
5, 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 that procedure code 22326 is not supported by the medical records submitted. 
 
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, the CPT Code Manual definition of 
code 22326 is "Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior 
approach, 1 fractured vertebra or dislocated segment; cervical." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite the using a 
reduction tool, was able to well reduce the fracture and fixate it. It was capped and finally tightened the rods 
bilaterally for fixation of the fracture. Therefore, the records do support that CPT 22326 was rendered in this 
case. 
 
We looked at this coder'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 pay for 
open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured 
vertebra or dislocated segment; cervical rendered on September 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 31, 2023. 
 
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 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 January 31, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant tooth 
#13 (D6010) provided on January 13, 2023. 
 
 
 You asked the Plan to pay for the dental services. You say that the Plan  approved you seeing the provider once 
so you should be able to continue to see them. You also say that you should not have to change oral surgeons. 
The Plan denied your request. The Plan says it was determined your dental provider was not contracting with 
the Plan at the time of service. Additionally, implants and related services are not covered by your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical placement of implant 
body: endosteal implant is not among those covered under this benefit. The record shows you received the 
requested dental service from an out-of-network provider. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the surgical placement of implant body: endosteal implant is 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 
surgical placement of implant body: endosteal implant tooth #13 (D6010) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and the treatment of root canal 
obstruction (D3331) for tooth #14 provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought all dental services were 100% 
covered and you would like the Plan to pay for the denied dental services. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the pulp vitality tests and the treatment of 
root canal obstruction are not 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, 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 pulp 
vitality tests (D0460) and the treatment of root canal obstruction (D3331) for tooth #14 provided on December 
5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210), the surgical 
removal of residual tooth (D7250), and bone replacement grafts (D7953) for tooth #18, #19, #20, #21, #22, 
#27, #28, #29, #30, and #31 provided by an out-of-network provider on November 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you they were an in-network 
provider, and you currently have temporary dentures and cannot eat with them. 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 surgical removal of erupted tooth (D7210), the surgical removal of residual tooth (D7250), and 
bone replacement grafts (D7953) for tooth #18, #19, #20, #21, #22, #27, #28, #29, #30, and #31 provided by an 
out-of-network provider on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) and the sales tax 
(S9999) purchased on December 7, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract pays for hearing aids only when 
purchased through the Plans select hearing aid provider. However, the hearing aids in this case were purchased 
from an out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aids (V5261) and the sales tax (S9999) purchased on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2330) for tooth #9 
provided on January 11, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were told you had $1,500 for the year 
of 2023 and that should have been enough to cover the dental services. The Plan denied your request. The Plan 
says your dental benefit for the year 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 on January 4, 2023, the Plan paid $175 for the dental services. On January 11, 2023, the Plan paid 
$1,325 for the dental services. For the year of 2023 the Plan paid $1,500 ($175 paid + $1,325 paid) for dental 
services; therefore, your benefit for the year was exhausted on the date of service of January 11, 2023. 
Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2330) for tooth 
#9 provided on January 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 6, 2022 to 
February 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the medical records provided 
support the home health services. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 6, 2022 to 
February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown - porcelain fused to high noble 
alloys (D6066) provided on January 5, 2023. 
 
You asked the Plan to pay for the implant supported crown - porcelain. You say that dental services are 
optional supplement services and you weren't told that you would have to pay for extra services. You also say 
that you were told that you had dental coverage when you signed up for Medicare advantage. The Plan denied 
your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant supported crown - porcelain fused to high noble alloys (D6066) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant and surgical access to an implant 
body for tooth number five. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 authorization number A0230323138219. 
Therefore, we decided that the Plan does not have to pre-approve an endosteal implant and surgical access to an 
implant body for tooth number five.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
December 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that the x-rays were out of necessity for the health of 
your teeth. 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 the date of service of August 9, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leg brace. 
 
You asked the Plan to pre-approve a leg brace. The Plan denied your request. The Plan says Healthcare 
Common procedure Coding System (HCPCS) code(s) and information of the durable medical equipment 
(DME) vendor that is dispensing the equipment, as well as clinical information is needed to establish medical 
necessity and make a decision. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a leg brace have been met. The 
provided records do not show any mention of your clinical course (worsening or improvement), prognosis, 
nature and extent of functional limitations, or other therapeutic interventions and results which are needed for 
this requested DME to be covered. Therefore, we decided that the Plan does not have to pre-approve a leg 
brace.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the thoracic spine 
(72070), x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbosacral spine (72100) 
provided on January 2, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), x-ray exam of the thoracic spine (72070), x-ray 
exam of the cervical spine (72040), and the x-ray exam of the lumbosacral spine (72100) provided on  
January 2, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 states that the step therapy requirement is not met and the services are 
not medically necessary; however, no medical records are presented for review. Without medical records, a 
determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-
approve Botox injections.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain fused to noble metal (D2752) provided on 
January 11, 2023. 
 
You asked the Plan to pay for dental services. You say that you were told this service would be covered. The 
Plan denied your request. The Plan says this service is not covered 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. Crown - porcelain fused to 
noble metal (D2752) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2752 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown - porcelain 
fused to noble metal (D2752) provided on January 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residential addiction program inpatient services (H0010) 
provided from March 23, 2022, to June 10, 2022. 
 
You asked the Plan to pay for the residential addiction program inpatient services. You say that the addiction 
rehabilitation intervention was necessary for your well-being, and at the time you received the services, 
necessary for your simple survival as a person and human being. You also say that without these services, you 
do not believe you could have successfully acclimated into recovery mode as you have done. The Plan denied 
your request. The Plan says the services in question are not covered by Medicare nor your Evidence of 
Coverage. The Plan also says that a substance abuse facility is not a covered provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Substance Abuse Facilities frequently attempt to 
enroll in Medicare but are not eligible to do so. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the residential addiction program inpatient services have not been met. Therefore, we decided that 
the Plan does not have to pay for the residential addiction program inpatient services (H0010) provided from 
March 23, 2022, to June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection into the corpora cavernosa with a pharmacologic 
agent rendered on November 29, 2022. 
 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says infertility testing and treatment or any sexual enhancement services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this injection is considered treatment of erectile dysfunction and as such. is not covered. Treatment 
of any sexual enhancement services are not covered.  
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for injection into the corpora cavernosa with a pharmacologic agent rendered on November 29, 
2022.