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

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), the surgical 
placement of implant body (D6010), a custom abutment (D6057), an implant supported to crown (D6065), the 
removal of impacted tooth (D7240), and the bone replacement graft (D7953), for tooth #3 and #18 to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you did not know the provider was out-of-
network and you would like the procedures covered. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve the guided 
tissue regeneration (D4266), the surgical placement of implant body (D6010), a custom abutment (D6057), an 
implant supported to crown (D6065), the removal of impacted tooth (D7240), and the bone replacement graft 
(D7953), for tooth #3 and #18 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve internal root repair of perforation defects for tooth 
number 12 (D3333). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. 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 requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve internal root 
repair of perforation defects for tooth number 12 (D3333).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213), and partial lower denture 
(D5214). 
 
You asked the Plan to pre-approve partial upper and lower dentures. 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 
partial upper denture (D5213), and partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0365), biologic materials (D4265), removal 
of impacted tooth (D7220), admin of nitrous oxide (D9230), non-intravenous conscious sedation (D9248), and 
therapeutic drug injection (D9610) provided on March 13, 2023, to March 15, 2023. 
 
You asked the Plan to pay for these dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 cone 
beam CT (D0365), biologic materials (D4265), removal of impacted tooth (D7220), admin of nitrous oxide 
(D9230), non-intravenous conscious sedation (D9248), and therapeutic drug injection (D9610) provided on 
March 13, 2023, to March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary, and you were not 
aware of the benefit limitations. 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 12, 2021. Therefore, 
we decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22510). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met given multifactorial etiology of 
enrollee's pain due to multiple disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration 
of retropulsion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22510).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient 
(D0150) provided on May 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 1, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient (D0150) provided on May 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not between the ages of 50-77. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital transfer. 
 
You asked the Plan to pre-approve the requested services. You say that you want the expertise of other doctors. 
The Plan denied your request. The Plan says there is not a higher level of care needed to warrant a transfer. 
 
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 requested services. Our physician 
reviewer found that you presented to the hospital with a fall and left ankle pain. Your workup showed an acute 
ankle fracture and fracture of the left tibia and fibula. The records do not show that the current hospital is not 
meeting your needs. The review has determined that the requested transfer is not medically reasonable or 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a hospital transfer.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 1, 2023. 
 
You asked the Plan to pay for home visit. You say that you should not have to pay the billed charges. The Plan 
denied your request. The Plan says the provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home visit provided on March 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624). 
 
You asked the Plan to pre-approve a genicular nerve ablation procedure. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a genicular nerve ablation procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found genicular nerve ablation is experimental for knee pain. 
 
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 genicular nerve ablation procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610), and anesthesia 
(D9222/D9223). 
 
You asked the Plan to pre-approve D9610, D9222 and D9223. You say that you have anxiety and need to have 
these additional services provided. The Plan denied your request. The Plan says these dental services have been 
correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of D9610, D9222 and D9223 have been 
met. Medical records were not provided to verify these services were medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610), and anesthesia 
(D9222/D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on December 9, 2022, through December 30, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided on December 9, 2022, 
through December 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on  
September 30, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the 
allowable benefit for the hearing aids purchased in this case.  
 
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.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of these items have not been met. Specifically, the Plans contract states that enrollees get 
up to $1,050 per hearing aid, per ear, every three years. The Plan issued payment in the amount of $1,050 for 
each hearing aid purchased on this day. The remaining balance of the left hearing aid purchased is the 
enrollees responsibility as she has exhausted the allowable benefit for the hearing aids purchased in this case.  
  
 
 
 
 
 
Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids purchased on 
September 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no evidence to support osteoarthritis in either knee.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 requested services. Our physician 
reviewer found that the enrollee has bilateral knee pain due to osteoarthritis of the knee. He has been treated 
with medications and corticosteroid injections. There is no documentation provided indicating that the enrollee 
has failed at least three months of conservative therapy. The review has determined that the documentation 
does not support that Synvisc is medically reasonable and necessary for this enrollee. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Synvisc injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 19, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment 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 November 21, 2022. The NOA was not received by the Plan until April 14, 
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 provided 
from February 19, 2023, to March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiographic/surgical implant index (D6190) provided April 
13, 2023. 
 
You asked the Plan to pay for D6190. You say that this service was medically necessary. The Plan denied your 
request. The Plan says the rendered dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
radiographic/surgical implant index (D6190) provided April 13, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care services provided from March 10, 
2023, to March 27, 2023. 
 You asked the Plan to pay for the nursing facility care services. You say that the enrollee was not enrolled in 
hospice on the dates of service. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 3, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the nursing facility 
care services provided from March 10, 2023, to March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim complete denture (maxillary) (D5810) provided 
on November 15, 2022. 
 
You asked the Plan to pay for the interim complete denture (maxillary). You say that you were told in the 
dental office they accepted your plan and you were advised you had to pay $53. You also say that you were 
told that you had to continue with services and if not, they could sue you. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the interim complete denture 
(maxillary) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for an interim complete denture (maxillary) (D5810) provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on April 
12, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that per the Plan's 2023 Enrollment 
guide you received this service should be covered. The Plan denied your request. The Plan says your benefit for 
the panoramic radiographic image has already been exhausted. The plan processed and paid for this service in 
line with the plans benefits. Service code D0210 is a related code to D0330 therefore, only one procedure can 
be carried out per three plan years. 
 
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 panoramic radiographic image was exhausted on date of service February 2, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a concern about the denial of the IRF 
admission. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.