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

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6245 x 4, D6740 x 2) for tooth 
number's 22-27. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the criteria for coverage have not been 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. The Plan covers the dental 
service when the services are medically necessary and reasonable. The Plan's rule to approve a bridge says you 
can only be missing one upper front tooth or two lower front teeth. The two lower front teeth must be next to 
each other. You also cannot be missing any of your back teeth. 
 
 
  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 dental service. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that in this instance there would be 
four lower anterior teeth to be replaced, namely 23, 24, 25, and 26. There are also numerous missing lower 
posterior teeth including tooth numbers 19, 20, 30 and 31, precluding coverage as per the criteria. Additionally, 
the periodontal status of tooth number 22 and 27 needs to also be addressed prior to any consideration of a 
bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge (D6245 x 4, D6740 x 2) for tooth number's 22-27.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 11, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,  
 consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee's condition stabilized and improved, and he was discharged the 
following day. The review has determined that the record did not show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on June 9, 2023, by an out-of-
network provider. 
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says a telehealth visit with an out-of-network provider is not 
covered. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that an in-network provider must be used for the out-of-network telehealth services benefit. 
 
We looked at the file and the Plans Evidence of Coverage. Out-of-network telehealth services must be 
rendered by an in-network provider. Based on this information, we decided that Medicare rules for coverage of 
the telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
telehealth visit provided on June 9, 2023, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on April 27, 2023, to May 25, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for acupuncture services. You say that you did not know that only one authorization 
request was sent for you to get out of network acupuncture services. The Plan denied your request. The Plan 
says the services are available in network. 
 
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 acupuncture services provided on April 27, 2023, 
to May 25, 2023, 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 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) provided on June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is the first and only time you have 
submitted a dental claim and you have not had any dental x-rays at all for over a year and never while you were 
using your healthcare insurance. You also say that you feel this must be a mistake. The Plan denied your 
request. The Plan says your benefit for the requested 2D oral/facial photographic image  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 service was exhausted on date of service June 6, 2023. The Plan has 
shown that On June 10, 2023, the Plan paid for one D0350 on the same claim for June 06, 2023 in the amount 
of $45.00 denying the remaining three as the frequency limit of one per 36 months has been met. Therefore, we 
decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on June 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on January 26, 2023, to January 
28, 2023, by an OON provider.  
 
You asked the Plan to pay for the inpatient care. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the inpatient care provided on January 26, 2023, to 
January 28, 2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 16, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were never 
admitted to inpatient status. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per day, for days 1 to 5 and a $0 copayment for the remainder of your covered hospital stay.  
 
 You have been asked to pay a $200 copayment per day, for 1 day of an inpatient hospital stay. You have not 
been charged for any additional days. This item/service falls within the inpatient hospital care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 16, 2023, to 
May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown - porcelain fused to noble metal (D6752), 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), and prefabricated post and core in addition to crown (D2954) provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had discussed receiving these services the 
year before but decided to wait until this year to receive the services because your maximum benefit would be 
higher this year.  You also say that you spoke to the plan and were advised the services would be covered 100%. The Plan 
denied your request. The Plan says your benefit for the retainer crown - porcelain fused to noble metal, 
intraoral - periapical first radiographic image, and intraoral - periapical each additional radiographic image has 
already been exhausted. The Plan also says there is no coverage for D2954 - prefabricated post and core in 
addition to crown. 
 
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 pay for the prefabricated 
post and core in addition to crown (D2954) provided on January 23, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image and intraoral - periapical each 
additional radiographic image was exhausted on date of service January 10, 2023. The record shows your 
benefit for the retainer crown  porcelain fused to high noble metal (D6752) was exhausted on the appealed 
claim. The Plan has shown that you already received and was covered for one (D6792) retainer crown on 
January 23, 2023. Therefore, we decided that the Plan does not have to pay for the retainer crown - porcelain 
fused to noble metal (D6752), intraoral - periapical first radiographic image (D0220), intraoral - periapical each 
additional radiographic image (D0230) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of x-ray images (D0210) provided on April 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee's was not aware they needed to use 
in-network providers and cannot afford to pay this claim. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by the enrollee's 
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 comprehensive oral evaluation (D0150) and complete series of x-ray images (D0210) provided 
on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on May 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the psychotherapy provided on May 5, 2023, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polysomnography to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the polysomnography. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 
the polysomnography to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service to replace broken teeth - per tooth (D5640) 
provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred by your primary care dentist 
and no one told you that they do not accept your insurance. You also say that you automatically assumed they 
accepted your insurance and you needed the assistance right away as you were in crisis with your broken teeth. 
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 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 service to replace broken teeth - per tooth (D5640) provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required tooth #'s 
29, 30 and 4 (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the crown build-up is required prior to crown 
placement to properly restore the tooth and adequately retain an indirect restoration. The Plan denied your 
request. The Plan says this service is not a covered expense under the enrollee's 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 service are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required tooth #'s 29, 30 and 4 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that it is difficult to get 
around, and you use a walker. You also say that you are a fall risk, and your knees are bone on bone. The Plan 
denied your request. The Plan says you do not meet the criteria for coverage. 
 
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 a group 1 standard power operated 
vehicle have been met. Specifically, there is no record of you having had a face-to-face evaluation for an 
electronic scooter by the physician within the past 6 months. There is no documentation of your inability to 
perform at least one mobility-related activity of daily living in the home and inability to operate a manual 
wheelchair or other manual mobility device, such as a walker. The provided documentation also does not 
include a home evaluation. Therefore, we decided that the Plan does not have to pre-approve a group 1 
standard power operated vehicle (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingivectomy or gingivoplasty to allow access for restorative 
procedure, per tooth (D4212) provided on March 22, 2023. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that for the past 35 years you have 
had many crowns and have never been denied this kind of procedure. You also say that the dentist told you that 
this is because recently, new dentists are using electrical equipment and that is why this is being denied. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) provided on March 
22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is a medical necessity and the clinical 
documents support the need for the requested home ventilator. The Plan denied your request. The Plan says the 
enrollee does not appear to have the severity of illness that would justify the need for a home mechanical 
ventilator.   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to chronic obstructive pulmonary disease (COPD). Claims for ventilators used to provide CPAP or 
bi-level CPAP therapy will be denied as not 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 a home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has severe 
obesity, obstructive sleep apnea, CPAP intolerant, and obesity hypoventilation syndrome. The enrollee was 
recently hospitalized for a hypertensive emergency and congestive heart failure. Arterial blood gas (ABG) was 
consistent with acute on chronic hyper carbic respiratory failure. There is no diagnosis for COPD, thoracic 
restrictive disease, or neuromuscular disease. The enrollee may benefit from BiPAP during sleep as an 
outpatient if compliance can be achieved. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP, the average volume-assured pressure support (AVAPS) mode can be provided via 
BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.