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

 
We decided that the Plan does not have to pay for periodontal maintenance and topical application of fluoride 
varnish (D1206, D4910) provided on May 5, 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 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 periodontal maintenance and topical application of fluoride varnish (D1206, D4910) provided on 
May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) and an implant support to 
crown (D6056) for tooth #10, #11, and #12 provided by an out-of-network provider on May 25, 2023, and June 
12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you started the process for implant and the 
previous provider was unable to continue and there was no other solution. 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 a prefabricated abutment (D6056) and an implant support to crown (D6056) for tooth #10, #11, and 
#12 provided by an out-of-network provider on May 25, 2023, and June 12, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on May 02, 2023, to May 22, 
2023. 
 
You asked the Plan to pay for occupational therapy. You say that you are requesting reconsideration of the 
denied claim. 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 occupational therapy 
provided on May 02, 2023, to May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement of a continuous positive airway 
pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve a CPAP replacement. You say that the item should be covered. The Plan 
denied your request. The Plan says your current CPAP machine is less than five (5) years old, and is not lost, 
stolen, or has irreparable damage, and the medical documentation does not indicate that your medical condition 
has changed such that the current equipment is no longer meeting you needs. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. While Medicare will not pay for a new device at this time, 
the company that supplied the recalled device has a program to repair or replace it. Therefore, we decided that 
the Plan does not have to pre-approve the replacement of a continuous positive airway pressure (CPAP) device 
(E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments to be rendered by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are available with an  
in-network provider.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  
 
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture treatments to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 8, 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 January 31, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
consultation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on August 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0157, G0299, Q5001) 
provided on January 6, 2023, to February 4, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 6, 2023. The NOA was not received by the Plan until March 10, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0157, G0299, Q5001) provided on January 6, 2023, to February 4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided on June 01, 2023, to June 28, 2023. 
 
You asked the Plan to pay for speech therapy. You say that you are requesting reconsideration of the denied 
claim. 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 speech therapy provided 
on June 01, 2023, to June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230), the complete 
upper denture (D5110) and an extraction (D7140) for tooth #18, #20, and #32 provided on June 6, 2023, and 
July 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you called the Plan, they did not tell you 
that the dentures would not be covered and that you had a $2,000 coverage. The Plan denied your request. The 
Plan says your benefit for the intraoral radiographic image has already been exhausted. The complete upper 
denture and an extraction are not covered by the Plan. Also, it was verified that you were given the correct 
information about in-network provider and the proper dental 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, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) on June 6, 2023; therefore, your benefit for 
the intraoral radiographic image (D0230) was exhausted on the date of service of June 6, 2023. The complete 
upper denture and an extraction are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for the intraoral radiographic image (D0230), the complete upper denture (D5110) 
and an extraction (D7140) for tooth #18, #20, and #32 provided on June 6, 2023, and July 27, 2023.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee can receive 
their care in another setting or in the current acute care setting. 
 
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 LTACH will not offer any services that are currently not present at the acute care 
hospital. Transfer to LTACH is not medically necessary. The enrollee can continue to be stabilized until they 
can be placed in skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on October 06, 
2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are requesting a 
reconsideration of the denied claim. 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 a $20 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. This item/service falls within the outpatient rehabilitation 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 copayment for physical 
therapy provided on October 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluation (D0150), panoramic x-
ray (D0330), computed tomography (CT) scan (D0383), dental case management (D9992), medicine to help 
patient relax for procedure (D9248), tooth extractions (D7140) of tooth #4, 9, 10, 11, 12, 13, and 21, bone 
material added (D6104) on tooth #4, 9, and 11, and surgery to place a metal post in jaw (D6010) for tooth #4, 
6, 8, 10, 12, and 13. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for comprehensive oral evaluation (D0150), 
panoramic x-ray (D0330), computed tomography (CT) scan (D0383), dental case management (D9992), 
medicine to help patient relax for procedure (D9248), tooth extractions (D7140) of tooth #4, 9, 10, 11, 12, 13, 
and 21, bone material added (D6104) on tooth #4, 9, and 11, and surgery to place a metal post in jaw (D6010) 
for tooth #4, 6, 8, 10, 12, and 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous, osteoperiosteal, or cartilage graft of the 
mandible or maxilla-autogenous or nonautogenous, by report for tooth number 12 (D7950) and a bone 
replacement graft for ridge preservation-per site for tooth number 12 (D7953). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an osseous, 
osteoperiosteal, or cartilage graft of the mandible or maxilla-autogenous or nonautogenous, by report for tooth 
number 12 (D7950) and a bone replacement graft for ridge preservation-per site for tooth number 12 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-rays, bitewing 
x-rays, and panoramic radiographic images (D0150, D0274, D0330, D0220, D0230) provided on July 18, 
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 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 a comprehensive oral evaluation, intraoral x-rays, bitewing x-rays, and panoramic radiographic 
images (D0150, D0274, D0330, D0220, D0230) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on July 24, 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. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on July 24, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 23, 2022, to 
December 19, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the records do not support the 
services as billed. 
 
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. Under the Patient-Driven Groupings Model (PDGM), the first 30-day period is 
classified as early. All subsequent 30-day periods in the sequence (second or later) are classified as late. In this 
case, the records support that the episode timing is correct. 
 
Additionally, under the PDGM, each 30-day period is classified into one of two admission source categories-
community or institutional-depending on what healthcare setting was utilized in the 14 days prior to home 
health admission. In this case, the records show that the enrollee was discharged from Sarah Bush Lincoln 
Hospital on November 16, 2022. 
 
We find that the Plan has not provided enough evidence to support the denial of payment for the home health 
services provided based on Medicare criteria. Therefore, we decided that the Plan has to pay for the home 
health services provided from November 23, 2022, to December 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on July 19, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service November 23, 2021.  
  
 
 
 
 
Specifically, the Plans contract states that one panoramic or full mouth x-ray is covered every 36 months. You 
previously a full mouth x-ray on November 23, 2021, less than 36 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan 
does not have to pay for the intraoral-comprehensive series of radiographic images (D0210) provided on  
July 19, 2023.