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

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057), and implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported porcelain/ceramic 
crown. You say that you had a tooth that broke off and your dentist had to pull out the tooth and place an 
implant there. You also say that you would like the crown covered because it would cost even more to place a 
bridge and fix the possible damage to the other surrounding teeth. The Plan denied your request. The Plan says 
you are only covered for the dental services, codes and limits listed in the medical benefits chart. 
 
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 a custom 
fabricated abutment  includes placement (D6057), and implant supported porcelain/ceramic crown (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter items purchased on March 10, 2023. 
 
You asked the Plan to pay for over-the-counter items. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says your claim submission was received more than 120 days after the 
date of service. The Plan also says that submissions must be received within 120 days of the date of service or 
items purchase to be reimbursed. 
 
Medicare generally does not cover over-the-counter services. However, the Plan offers an over-the-counter 
benefit under the pick your perks reimbursement program that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case.  
 
 
  The Plan rules say although that they do cover over-the-counter items in the pick your perks reimbursement 
program, you have 120 days from the purchase/date of service to submit your reimbursement claim and 
required documentation. The record shows the reimbursement claim was received on September 19, 2023, 
which is more than 120 days from the date services were received.  Therefore, we decided that the Plan does 
not have to pay for over-the-counter items purchased on March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0220 and D7140) on August 4, 2021. 
 
You asked the Plan to pay for the dental services (D0220 and D7140). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services requested are not 
covered 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D0220 and D7140) on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compression devices to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression devices to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220), a resin-based 
composite (D2331) for tooth #26 and #27, a custom fabricated abutment (D6057) for tooth #14, and a crown 
anchored to an implant (D6058) for tooth #14 provided by an out-of-network provider on February 23, 2023, 
and March 14, 2023. 
 You asked the Plan to pay for the dental services. You say that you changed your insurance based on dental 
coverage and you did not plan on changing your dentist. 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 the intraoral radiographic images (D0220), a resin-based composite (D2331) for tooth #26 and #27, a 
custom fabricated abutment (D6057) for tooth #14, and a crown anchored to an implant (D6058) for tooth #14 
provided by an out-of-network provider on February 23, 2023, and March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (00170 and 41899). 
 
You asked the Plan to pre-approve the dental services (00170 and 41899). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the services requested are not covered 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services (00170 and 41899).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that 
Evenity is not medically necessary. Our physician reviewer found that the enrollee has age related osteoporosis 
without osteoporotic fracture and the medication is a new start. However, there is no indication that the enrollee 
has tried and failed the Plan's preferred step one alternative. Also, there is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 2, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were seen for spinal manipulation. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
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 provided by a chiropractor on August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous decompressive laminotomy/laminectomy 
under image guided fluoroscopy. 
 
You asked the Plan to pre-approve percutaneous decompressive laminotomy/laminectomy under image guided 
fluoroscopy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 percutaneous decompressive 
laminotomy/laminectomy under image guided fluoroscopy. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
considered experimental/ investigational therapy at this time. Therefore, the request is deemed not medically reasonable and 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 percutaneous decompressive laminotomy/laminectomy under image guided 
fluoroscopy. have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
decompressive laminotomy/laminectomy under image guided fluoroscopy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any complex wounds, changes in clinical status, medications or plan of care. 
The records do not show that 4 additional home health skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance 
program to maintain your condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture-flexible base (D5226). 
 
You asked the Plan to pre-approve 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 July 8, 2022. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture-flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on July 24, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you realize the provider is out-of-
network, but you failed to see clearly where to find who is in-network in your area. The Plan denied your 
request. The Plan says there is no coverage for hearing aids when received from a provider other than the Plan 
hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you obtain the hearing aids through a Plan network hearing provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5298) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0330) on September 6, 2023. 
 
You asked the Plan to pay for the dental service (D0330). You say that you would like to request 
reconsideration for payment. 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 30, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental service (D0330) on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided on August 8, 2023. 
 
You asked the Plan to pay more for the endodontic therapy. You say that this was an emergency service 
because you had lockjaw for 3 days. You also say that you don't think you should have to pay anything since 
this was an emergency. The Plan denied your request. The Plan says your benefit for the requested service 
$2,500 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested endodontic therapy has been exhausted. The Plan has provided evidence 
of having made payments totaling $2,500 towards the cost of dental services in 2023. This included a partial 
payment of $872 towards the endodontic therapy in dispute. Once this payment was made, the yearly benefit 
maximum was reached. Therefore, we decided that the Plan does not have to pay more for the endodontic 
therapy, molar tooth (excluding final restoration) (D3330) provided on August 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 additional trips for routine transportation. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you have unlimited 
transportation benefits. The Plan denied your request. The Plan says you have 2 trips remaining before 
exhausting your benefit for the calendar year. 
 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 72 trips per year.  
 
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 60 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on April 17, 2023. 
 
You asked the Plan to reimburse for over-the-counter items purchased. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says your claim submission was received more 
than 120 days after the date of service. The Plan also says that submissions must be received within 120 days of 
the date of service or items purchase to be reimbursed. 
 
Medicare generally does not cover over-the-counter services. However, the Plan offers an over-the-counter 
benefit under the pick your perks reimbursement program that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case. 
 
 
  The Plan rules say although that they do cover over-the-counter items in the pick your perks reimbursement 
program, you have 120 days from the purchase/date of service to submit your reimbursement claim and 
required documentation. The record shows the reimbursement claim was received on September 19, 2023, 
which is more than 120 days from the date services were received. Therefore, we decided that the Plan does not 
have to reimburse for over-the-counter items purchased on April 17, 2023.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee currently requires two therapists to assist with all the 
functional mobility tasks and a therapists note increased pain during therapy sessions. The Plan says the 
enrollee will not be able to tolerate an intensive rehabilitation regimen consisting of 3 hours of daily therapies. 
The Plan says services may be provided at a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the 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 pre-approve core buildups (D2950 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure is required to get crowns in 
your case. You checked with other providers, and none would put a crown on without a core build. The Plan 
denied your request. The Plan says this service is not a covered benefit 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 core 
buildups (D2950 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement inlay, onlay, veneer, or partial (D2910) for 
tooth #30 provided on November 23, 2022. 
 
You asked the Plan to pay for the dental servic. You say that you resubmitted the invoice with the code 
provided by the dentist office. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the re-cement inlay, onlay, veneer, or partial 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 the re-
cement inlay, onlay, veneer, or partial (D2910) for tooth #30 provided on November 23, 2022.