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

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953), collection and application of autologous blood concentrate product (D7921), extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210), and a limited oral evaluation - problem focused (D0140) provided on April 17, 2023. 
 You asked the Plan to pay for the dental services. You say that you are requesting reimbursement for the total 
paid of $1496.00 for the dental services. The Plan denied your request. The Plan says your benefit for the 
requested item or service $2,000 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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $2,000 towards the cost of dental services provided in 2023. Since your annual maximum 
has been satisfied no additional payment will be made towards these services. Therefore, we decided that the 
Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953), collection 
and application of autologous blood concentrate product (D7921), extraction, erupted tooth requiring removal 
of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and a 
limited oral evaluation - problem focused (D0140) provided on April 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy (97530, 97140) provided 
on January 31, 2023. 
 
You asked the Plan to waive the coinsurance for physical therapy (97530, 97140). You say that you do not 
agree with the coinsurance for this visit. 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 20% 
coinsurance for outpatient rehabilitation service. 
 
You have been asked to pay 20% coinsurance for physical therapy (97530, 97140). This item/service falls 
within the outpatient rehabilitation service 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. The total you owe is $19 ($95 allowed amount x 20% = $19). Therefore, we 
decided that the Plan does not have to waive the coinsurance for physical therapy (97530, 97140) provided on 
January 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on May 2, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that after a vital check there 
was no need to go to the hospital. The Plan denied your request. The Plan says without transport there is no 
payable service. 
 
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 May 2, 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 services without transport received 
on May 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on October 15, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the claim to be reprocessed 
and paid. The Plan denied your request. The Plan says you have exceeded the timeline for filing. 
 
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 ambulance services was not filed until March 17, 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 ambulance services provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty not in conjunction with extractions - 
four or more teeth or tooth spaces, per quadrant (D7320). 
 
You asked the Plan to pre-approve the alveoloplasty. You say that your provider said you need this procedure 
done in order to relieve your pain. The Plan denied your request. The Plan says dental code D7320 is not listed 
in the chart and therefore is not a covered code. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) for tooth #19 provided on 
June 26, 2023. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why endodontics is only 
covered on certain teeth. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the endodontic therapy 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 endodontic therapy with dental 
code D3330 is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for the endodontic therapy (D3330) for tooth #19 provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia  first 15 minutes (D9222), 
deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), surgical placement of 
implant body: endosteal implant (D6010), and bone graft at time of implant placement (D6104) provided on 
April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that due to the severity of your dental condition, you 
had no choice but to have this procedure done. You also say that you could wait no longer due to the 
excruciating dental pain, headaches and weight loss. 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 deep sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each 
subsequent 15 minute increment (D9223), surgical placement of implant body: endosteal implant (D6010), and 
bone graft at time of implant placement (D6104) provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 7, 
2023. 
 
You asked the Plan to pay for the extraction. You say that you are requesting a reconsideration and you have 
submitted the necessary x-ray to reprocess and pay the claim. The Plan denied your request. The Plan says your 
benefit for the requested service $2,000 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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $2,000 towards the cost of dental services provided in 2023. Since your annual maximum 
has been satisfied no additional payment will be made towards the appealed service. Therefore, we decided that 
the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on June 23, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for gauze. You say that you are requesting reconsideration asking for the medical 
records to be reviewed. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for gauze provided on June 23, 2023, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stay in a skilled nursing facility from February 26, 2023, to 
March 3, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that continued stay in a skilled nursing facility 
was medically necessary.  The Plan denied your request. The Plan says 100 days of SNF care have been 
exhausted. 
 
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 the enrollee received 100 days of SNF care during the benefit period from February 6, 
2023, to July 25, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for a stay in a skilled nursing facility from February 26, 2023, to March 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and the refraction provided on 
June 6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye examination and the refraction. You say that the provider's office 
told you that your exam would be covered. The Plan denied your request. The Plan says the provider was out-
of-network and authorization was not obtained. The Plan contract also says the refraction is not a covered 
benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
medical eye examination and the refraction. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the medical eye examination and 
the refraction provided on June 6, 2023, by an out-of-network (OON) provider.
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 need extensive rehabilitation to regain your 
health and mobility. The Plan denied your request. The Plan says that there is no need for an intensive 
rehabilitation program.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
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 dental services provided on February 2, 2022. 
 
  You asked the Plan to pay for dental services. You say that your claim was combined with your husband. You 
also say you had the dentist separate your dental accounts. The Plan denied your request. The Plan says 
because they did not receive the request within 365 from the original date of service, this request for 
reimbursement was correctly denied for dental services received on February 2, 2022. 
 
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 dental services was not filed until May 9, 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 dental services provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on February 19, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2023, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on February 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on March 1, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2023, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower grab bar (E0241). 
 
You asked the Plan to pre-approve a grab bar. You say that the item should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says the item denied correctly as they are excluded 
from Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a shower grab bar (E0241).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum socket system (L5781). 
 
You asked the Plan to pre-approve a vacuum socket system. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says that the requested item is 
experimental/investigational. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 a vacuum socket system. Our reviewer 
says that a vacuum socket system is medically reasonable and necessary in this case. Our physician reviewer 
found that your need for all the requested parts of this prosthesis is adequately described by the provided 
medical records in a way that more than satisfies general Medicare documentation requirements for the entirety 
of the requested prosthesis, including for L5781. The Plan's policy declares this technology to be experimental 
and generally non-covered; however, we note that all 9 of the cited studies reported on the benefits of using 
vacuum suspension in properly selected amputee patients, most with statistically significant findings. This 
renders moot the Plans objections about sample size. The vacuum assisted socket system (VASS) is very much in the mainstream of standards of prosthetic care. There is no doubt that traditional Medicare would cover the 
entirety of the requested prosthesis for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vacuum socket system have been met. Therefore, we decided that the Plan has 
to pre-approve a vacuum socket system (L5781).  
 
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.