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

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to predominantly base 
metal tooth # 15 (D6751). 
 
You asked the Plan to pre-approve to pre-approve a retainer crown - porcelain fused to predominantly base 
metal tooth #'s 13 and 15 (D6751), and pontic - porcelain fused to predominantly base metal (D6241). You say 
that the summary of benefits states the plan covers bridges, not just two parts of the device.  You also say to please review the submitted pretreatment estimate. The Plan denied your request. The Plan says 
your benefit for the retainer crown - porcelain fused to predominantly base metal 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 retainer crown - porcelain fused to predominantly base metal was already approved 
the allowed frequency of a crown bridge for tooth #13 on the appealed claim. Therefore, we decided that the 
Plan does not have to pre-approve a retainer crown - porcelain fused to predominantly base metal tooth #15 
(D6751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (removal of appliances, 
construction, and placement of a retainer) (D8680) provided on June 20, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the orthodontic 
retention (removal of appliances, construction, and placement of a retainer) (D8680) provided on June 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on April 4, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that all your dentists feel the need to 
perform a comprehensive oral evaluation instead of just cleaning your teeth. You also say this is disappointing 
as you only want a cleaning. The Plan denied your request. The Plan says your benefit for the comprehensive 
oral evaluation 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 service was exhausted on date of service January 19, 2022. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on April 12, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you are on a fixed income. You also 
say that you would appreciate the Plan's financial help in this matter. The Plan denied your request. The Plan 
says there is no coverage for hearing aids when received from a provider other than the Plan hearing 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 the hearing aids are obtained through a Plan hearing provider.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that you must obtain prior authorization from the 
Plan hearing. The Plan rules also say that hearing aids purchased outside of the Plan hearing are not covered. 
The record shows that these hearing aids were purchased outside of the Plan hearing. Based on this 
information, we decided that the Plan's rules for coverage of hearing aids (V5298) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for hearing aids (V5298) purchased on April 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310), and extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided on April 28, 2023. 
 
You asked the Plan to pay for the alveoloplasty and extractions. You say that the bill is too high and you were 
told the extractions would be covered under your plan. The Plan denied your request. The Plan says your 
benefit for the requested services $1,000 dollar limit was met. 
 
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 serviced was exhausted on dates of service April 6, 2023 and April 28, 
2023. The records indicate that the $1,000 annual maximum has been satisfied by claim numbers ending in 
44683, $40.00, and claim 98820, $960.00 ($40.00 + $960.00 = $1,000.00). Since your annual maximum has 
been satisfied by these claims, no additional payment will be made towards claim 98820.Therefore, we decided 
that the Plan does not have to pay for the alveoloplasty in conjunction with extractions - four or more teeth or 
tooth spaces, per quadrant (D7310), and extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140) provided on April 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3-R MIS device. 
 
You asked the Plan to pre-approve  the Minuteman G3-R MIS device . You say that the enrollee has suffered 
from persistent radicular back pain. The appellant says the minimally invasive spinal fusion procedure is 
medically necessary. The Plan denied your request. The Plan says the Minuteman device is not medically 
necessary. The Plan says the Minuteman device is considered experimental.  
 
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 Minuteman G3-R MIS device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental, and more research is needed. 
 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 Minuteman G3-R MIS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Minuteman G3-R MIS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364), an apicoectomy (D3410), and a 
retrograde filling (D3430) for tooth #7 provided on April 20, 2023, to April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that the dental services should be 
paid under your medical benefit because it was done by an endodontist. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the cone beam, an apicoectomy, and a 
retrograde filling 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. 
 
The requested cone beam, apicoectomy, and the retrograde filling in dispute meets the Medicare definition of 
dental, since it is a service which involved the care and treatment of teeth or structures directly supporting the 
teeth. The cone beam, apicoectomy, and the retrograde filling does not fall under any of Medicare exceptions 
for coverage of non-routine dental care. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested items or services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for a cone beam (D0364), an apicoectomy (D3410), and a retrograde 
filling (D3430) for tooth #7 provided on April 20, 2023, to April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the massage therapy provided on 
November 22, 2022 and December 7, 2022.  
 
 You asked the Plan to issue reimbursement 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 rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The Plan's rules for coverage of gym benefits have not been met because the massage therapy provided in this 
case is not covered under the wellness allowance benefit. Therefore, we decided that the Plan does not have to 
issue reimbursement for the massage therapy provided on November 22, 2022 and December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out of network oral exam and intraoral 
complete x-rays provided on June 15, 2023. 
 
You asked the Plan to waive the coinsurance for an oral exam. You say that you were told this would be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for out of network oral exams. Intraoral complete x-rays are not a covered benefit. 
 
You have been asked to pay 50% coinsurance for an oral exam. This item/service falls within the out of 
network dental services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an out of 
network oral exam and intraoral complete x-rays provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture and manual therapy techniques provided on 
February 17, 2023, to March 9, 2023. 
 
You asked the Plan to pay for acupuncture and manual therapy techniques. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says acupuncture is not covered when solely provided by 
an independent acupuncturist. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for acupuncture and manual therapy techniques provided on February 17, 2023, to March 
9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling, endodontic therapy, and dental consultation 
(D2391, D9310, D3320) provided on May 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges and were not made aware of the providers network status. The Plan denied your request. The 
Plan says the services denied correctly as they do not fall within your Plan benefits. 
 
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 a filling, endodontic therapy, and 
dental consultation (D2391, D9310, D3320) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care and debridement provided on April 
12, 2023. 
 
You asked the Plan to pay for the nursing facility care and debridement. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility care 
and debridement provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site 
(D4266), surgical placement of implant body: endosteal implant (D6010), and sinus augmentation with bone or 
bone substitutes via a lateral open approach (D7951)  provided on September 21, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D4266, D6010 and D7951. You say that 
the option plan states it covers 50% of restorative and major services. The Plan denied your request. The Plan 
says these services are not covered. The Plan also says that charges for any type of implant and all related 
services, including crowns or the prosthetic device attached to it; precision or semi-precision attachments; over-
dentures and any endodontic treatment associated with over-dentures; other customized attachments are 
excluded from coverage. 
 
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 guided 
tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal 
implant (D6010), and sinus augmentation with bone or bone substitutes via a lateral open approach (D7951)  
provided on September 21, 2022.
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 you require assistance with daily tasks as well as 
physical, occupational and speech therapy services. The Plan denied your request. The Plan says you do not 
meet the criteria for admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pill box (E1399). 
 
You asked the Plan to pre-approve a pill box. You say that you need this item. The Plan denied your request. 
The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a pill box (E1399).
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 enrollee requires a stay at an acute rehabilitation 
facility to regain the ability to return to function as normal as possible. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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 a comprehensive periodontal evaluation (D0180) provided 
on March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with 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 date of service October 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) 
provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230), and prefabricated post and core in addition to crown (D2954) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had not had x-rays prior to this visit and 
was advised that the services would be covered. The Plan denied your request. The Plan says your benefit for 
the intraoral - periapical each additional radiographic image has already been exhausted. The Plan also says 
that the prefabricated post and core in addition to crown (D2954) 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 Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated post and core in 
addition to crown (D2954) is not among those covered under this benefit. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical each additional radiographic image was exhausted on date of 
service April 17, 2023. You already received the allowed frequency of 1 intraoral - periapical first radiographic 
image (D0220) on the appealed claim. Therefore, we decided that the Plan does not have to pay for an intraoral 
- periapical each additional radiographic image (D0230), and prefabricated post and core in addition to crown 
(D2954) provided on April 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluorouracil. 
 
You asked the Plan to pre-approve Fluorouracil. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 pre-approve Fluorouracil.  Benefits for Fluorouracil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.