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

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953) and surgical removal of 
residual tooth roots (D7250 x5). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the surgical removal of residual tooth roots 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 surgical removal of residual tooth roots was exhausted. A bone replacement graft is not a covered service. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft 
(D7953) and surgical removal of residual tooth roots (D7250 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), and panoramic radiographic image (D0330), provided on August 9, 2023. 
 
You asked the Plan to pay for the periodic oral evaluation - established patient, prophylaxis - adult, and 
panoramic radiographic image. You say that you seldom go to the dentist except for your semi-annual dental 
check-up and examination which is a routinely accompanied by a tooth cleaning. You also say that you have 
done nothing different than what you have done for years such as reporting to your dentist when the office 
contacts you to schedule an appointment. The Plan denied your request. The Plan says your benefit for the 
periodic oral evaluation - established patient, and prophylaxis - adult has already been exhausted. The Plan also 
says that the panoramic radiographic image is not a covered expense under 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, certain limitations apply. The record 
shows your benefit for the periodic oral evaluation - established patient and prophylaxis - adult was exhausted 
on date of service January 2, 2023. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation - established patient (D0120), and prophylaxis - adult (D1110), provided on August 9, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic radiographic image is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic radiographic image (D0330), provided on August 9, 2023. 
 
Your complaints about the Plan 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) for tooth #3. 
 
You asked the Plan to pay for the dental service. You say that your previous crown was defective, and it is 
causing you pain. 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 the Plan paid for a crown (D2750) for tooth #3 on December 7, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 7, 2021. Therefore, we decided 
that the Plan does not have to pay for a crown (D2750) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6245), and retainer crowns (D6740). 
 
You asked the Plan to pay for D6245 and D6740. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the requested dental services are not covered 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 pontics 
(D6245), and retainer crowns (D6740).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on June 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
after receiving fluids your condition changed and there was no need to go to the hospital. The Plan denied your 
request. The Plan says without transport there are no payable charges. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on June 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in tissue regeneration. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered 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 pre-approve 
biologic materials to aid in tissue regeneration (D3431).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the enrollee has many 
appointments and engagements where they need to be mobile, and the large tanks are not portable. The Plan 
denied your request. The Plan says that Medicare does not cover oxygen equipment that is needed for travel or 
other uses outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on March 2, 2023. 
 
You asked the Plan to reimburse for over-the-counter items. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your claim submission was received more than 120 days 
after the date of service. The Plan also says that submissions must be received within 120 days of the date of 
service or items purchase to be reimbursed. 
 
Medicare generally does not cover over-the-counter services. However, the Plan offers an over-the-counter 
benefit under the pick your perks reimbursement program that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case.  
 
 
  The Plan rules say although that they do cover over-the-counter items in the pick your perks reimbursement 
program, you have 120 days from the purchase/date of service to submit your reimbursement claim and 
required documentation. The record shows the reimbursement claim was received on September 19, 2023, 
which is more than 120 days from the date services were received. Therefore, we decided that the Plan does not 
have to reimburse for over-the-counter items purchased on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your previous dentures, and you 
need new dentures. The Plan denied your request. The Plan says your benefit for the requested items or 
services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a partial upper denture (D5213) and a partial lower denture (D5214) on March 25, 
2020; therefore, your benefit for the requested items or services was exhausted on the date of service of March 
25, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and 
a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implants (D6010 x2), custom 
fabricated abutments (D6057 x2), extractions (D7210 x4), bone replacement grafts (D7953 x12), and guided 
tissue regeneration (D7956 x12). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your benefits for the implants, custom fabricated abutments, and 
extractions have already been exhausted. Bone replacement grafts and guided tissue regeneration are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the implants, custom fabricated abutments, and extractions was exhausted. Additionally, 
bone replacement grafts and guided tissue regeneration are not covered benefits. Therefore, we decided that the 
Plan does not have to pre-approve surgical placement of implants (D6010 x2), custom fabricated abutments 
(D6057 x2), extractions (D7210 x4), bone replacement grafts (D7953 x12), and guided tissue regeneration 
(D7956 x12).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation or replacement of device for intrathecal or 
epidural drug infusion; programmable pump (62362), and implantation, revision or repositioning of tunneled 
intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable 
reservoir/infusion pump; without laminectomy (62350).  
You asked the Plan to pre-approve implantation or replacement of device for intrathecal or epidural drug 
infusion; programmable pump, and implantation, revision or repositioning of tunneled intrathecal or epidural 
catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; 
without laminectomy. You say that this is medically necessary. The Plan denied your request. The Plan says 
this is not medically necessary because the records show the enrollee has an active infection in the stage 4 
pressure ulcer to the ischium with possible osteomyelitis. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of an infusion pump is contraindicated 
for patients with an active infection. 
 
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 implantation or replacement of device 
for intrathecal or epidural drug infusion; programmable pump, and implantation, revision or repositioning of 
tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or 
implantable reservoir/infusion pump; without laminectomy. Our reviewer says that the enrollee does not meet 
criteria for coverage. Our physician reviewer found the records in this case document the patient has a stage 4 
ischial pressure ulcer positive for methicillin resistant staphylococcus aureus that was recently treated with 
antibiotics and debridement, and which requires further evaluation with imaging to rule out osteomyelitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation or replacement of device for intrathecal or epidural drug infusion; 
programmable pump, and implantation, revision or repositioning of tunneled intrathecal or epidural catheter, 
for long-term medication administration via an external pump or implantable reservoir/infusion pump; without 
laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation 
or replacement of device for intrathecal or epidural drug infusion; programmable pump (62362), and 
implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication 
administration via an external pump or implantable reservoir/infusion pump; without laminectomy (62350).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve the injection. You say that previous procedures did not provide you any pain 
relief. The Plan denied your request. The Plan says a platelet rich plasma injection is considered experimental 
and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at 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 pre-approve a 
platelet rich plasma injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 4, D6752 x 2) and a pontic 
(D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you have been suffering from dental 
problems and your providers treatment plan was denied. You cannot afford these services on your own. 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 on authorization 
202309276077940. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740 x 
4, D6752 x 2) and a pontic (D6245).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide SNF care from June 1, 2023, to July 1, 2023. 
 
You asked the Plan to provide SNF care. You say that you are unable to walk, dress yourself, or do other daily 
activities by yourself. The Plan denied your request. The Plan says you exhausted 100 days of SNF coverage 
and did not have a 60-day period between dates of service and the requested new coverage date. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from January 1, 2023, to June 
1, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to provide SNF care from June 1, 2023, to July 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that you need a replacement because your 
provider wants to extract the teeth holding your partial denture in. 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 July 13, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array - Sprint PNS x2. 
 
You asked the Plan to pre-approve the implantation of the Sprint PNS. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. The Plan says 
there is insufficient medical literature to support the use of the Sprint PNS system for chronic pain. 
 
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 pre-approve the implantation of the Sprint PNS. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the service is considered an experimental/investigational procedure. There are 
ongoing clinical trials of the Sprint PNS for knee pain. Therefore, the request is deemed not medically reasonable and necessary. 
 
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 implantation of the Sprint PNS have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array - 
Sprint PNS x2.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are medically 
necessary. The Plan denied your request. The Plan says you have exhausted your benefit for the calendar year. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided from June 29, 2022, to July 18, 
2022. 
 
You asked the Plan to pay for the physical therapy. You say that the provider has already been paid. The Plan 
denied your request. The Plan says the claim was filed untimely without good cause. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physical therapy was not filed until August 1, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the physical therapy provided from June 29, 2022, to July 18, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational, speech, and physical therapy services 
provided from June 1, 2022, to June 30, 2022. 
 
You asked the Plan to pay for the occupational, speech and physical therapy. You say that you were not 
informed or aware of the time frame allowed for the claim. The Plan denied your request. The Plan says the 
claim was filed late without good cause. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the occupational, speech and physical therapy was not filed until August 7, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the occupational, speech, and physical 
therapy services provided from June 1, 2022, to June 30, 2022.