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

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), custom 
fabricated abutment (D6057), and abutment supported porcelain or ceramic crown (D6058). 
 
You asked the Plan to pre-approve surgical placement of implant body, custom fabricated abutment, and 
abutment supported porcelain or ceramic crown. You say that you are in the middle of a three part implant. 
You also say you are requesting your $1,000 dental allowance to be utilized for this procedure. The Plan denied 
your request. The Plan says implant services are not covered under your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body (D6010), custom fabricated abutment (D6057), and abutment supported 
porcelain or ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical additional radiographic image 
(D0230) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental service. You say that at the time of your visit, an office staff member 
may have contacted the plan on behalf of the services that would be rendered. You also say that you or your 
spouse at the time were not advised of any changes that might have been made so you could make a choice on 
whether or not to refuse the services. 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 August 15, 2023. You 
already received the allowed frequency of an intraoral x-ray (D0220) on the appealed clalim. Therefore, we 
decided that the Plan does not have to pay for the intraoral - periapical additional radiographic image (D0230) 
provided on August 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on March 
4, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on March 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on July 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had pain in your tooth and the x-ray showed 
your tooth needed to be pulled. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for bitewings (D0274) on February 1, 2023; therefore, your benefit for the requested item 
or service was exhausted on the date of service of February 1, 2023. Therefore, we decided that the Plan does 
not have to pay for the bitewings (D0274) provided on July 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous decompression spacer (Superion 
Vertiflex) procedure. 
 
You asked the Plan to pre-approve the Superion Vertiflex procedure. You say that this procedure is necessary 
due to the failure of conservative treatments to address pain and restore function. The Plan denied your request. 
The Plan says this procedure is not supported by research and is not covered. 
 
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 Superion Vertiflex procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Superion Vertiflex procedure is considered 
experimental/investigational and is not medically necessary for the treatment of chronic back 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 the Superion Vertiflex procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the interspinous decompression spacer (Superion Vertiflex) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation (general anesthesia). 
 
You asked the Plan to pre-approve deep sedation (general anesthesia). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the requested 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 pre-approve deep 
sedation (general anesthesia).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crown (D2750). 
 
You asked the Plan to pre-approve porcelain fused to high noble metal crown (D2750). You say that you are 
appealing with the supporting records. The Plan denied your request. The Plan says your dental benefit does 
not cover the requested 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 pre-approve 
porcelain fused to high noble metal crown (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3020). 
 
You asked the Plan to pre-approve the foot inserts. You say that you would like for this item to be covered. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3020).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653, and 87641 billed for 
date of service August 16, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, and 87641. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87798, 87481, 87653, 
and 87641 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87798, 
87481, 87653, and 87641 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653, and 
87641 billed for date of service August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 28 miles each way for an appointment. 
 
You asked the Plan to pre-approve an additional 28 miles each way for an appointment. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says you have exceeded your 
benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles driving distance for each one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 28 miles each way for an appointment.
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 September 15, 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 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 December 21, 2021.  
  
 
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images is 
covered every three years. You previously received this service on December 21, 2021, less than three years 
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 September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings-four radiographic images (D0274) provided on 
October 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that your former dentist has dropped coverage 
forcing you to find another in-network provider. You say as a new patient, their procedure is to take 
radiographic images to determine the condition of a new patient. You say since your former dentist dropped 
coverage, you believe your new provider's process for new patients is justified and 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 13, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings-four radiographic images (D0274) 
provided on October 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutment (D6191) and implant 
/abutment supported removable denture for edentulous arch  mandibular (D6111). 
 
You asked the Plan to pre-approve semi-precision abutment (D6191) and implant /abutment supported 
removable denture for edentulous arch  mandibular (D6111). You say that you feel it should be covered since 
you believe the implant job was done wrong leading to it breaking. The Plan denied your request. The Plan 
says this is 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 pre-approve 
semi-precision abutment (D6191) and implant /abutment supported removable denture for edentulous arch  
mandibular (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245 x 2), retainer crowns (D6740 x 3), re-
cement or re-bond fixed partial denture (D6930) and fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
pontics (D6245 x 2), retainer crowns (D6740 x 3), re-cement or re-bond fixed partial denture (D6930) and 
fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia services in a hospital setting. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit in the requested setting under your 
dental plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 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. Additionally, the services you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of the enrollees teeth or the structures directly 
supporting the enrollees teeth. These are dental services that are not covered or paid for by Medicare under 
your medical benefit. Therefore, we decided that the Plan does not have to pre-approve anesthesia services in a 
hospital setting.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an overdenture-complete mandibular (D5865) provided on 
August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of the benefit limitation of 
five year frequency to receive dentures. You say you need the dentures to be able to eat your food. 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 September 23, 2021. Therefore, we decided that the Plan does not have to pay for an overdenture-complete mandibular (D5865) 
provided on August 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 5, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on December 
5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the criteria for an LTACH admission 
has not been met. 
 
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 the enrollee appears to be stable, but vent-dependent with current treatment and 
should only require short-term additional acute care hospital services that can safely be provided at the current 
facility until more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic image 
(D0230), and the endodontic therapy, of a molar tooth (excluding final restoration) (D3330) provided on 
September 7, 2023.  
 
You asked the Plan to pay for the dental services. 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 services 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 services provided was previously exhausted. Specifically, the Plans contract states 
that two limited oral evaluations are covered per year. You previously received these services on March 8, 
2023 and July 6, 2023 accordingly, which were paid for by the Plan. Additionally, the Plans contract states 
that there is a $1,500 annual maximum dental benefit. The Plan previously issued payments for the total 
amount of $1,500 for dental services provided in the 2023 calendar year. Therefore, you have exhausted the 
allowable benefit for the services provided in this case. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image 
(D0220), intraoral-periapical additional radiographic image (D0230), and the endodontic therapy, of a molar 
tooth (excluding final restoration) (D3330) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework 
with resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin denture 
bases (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are asking for replacement of dentures 
as the set you received in March of 2022 have been damaged. 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 March 10, 2022. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal 
framework with resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin 
denture bases (D5214).