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

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460), and a limited oral evaluation - 
problem focused (D0140) provided on June 12, 2023. 
 
You asked the Plan to pay for the pulp vitality tests and limited oral evaluation. You say that this service should 
be covered because you had an infection in the tooth. You also say that you do not understand how you 
exceeded limited frequency when you never had it done before. The Plan denied your request. The Plan says 
your benefit for the  limited oral evaluation has already been exhausted. The Plan also says that the pulp vitality 
tests are not covered 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, pulp vitality tests (D0460) are not 
among those covered under this benefit. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused was exhausted on date of service May 9, 
2023. Therefore, we decided that the Plan does not have to pay for pulp vitality tests (D0460), and a limited 
oral evaluation - problem focused (D0140) provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and a limited oral evaluation - problem focused (D0140) provided on November 22, 2022. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image and a limited oral evaluation. 
You say that you were not informed  the services were not covered and you cannot afford to pay for it. The 
Plan denied your request. The Plan says your benefit for the requested services 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 limited oral evaluation - problem focused was exhausted on date of service July 26, 
2022, and the intraoral - periapical first radiographic image was exhausted on date of service August 17, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), and a limited oral evaluation - problem focused (D0140) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on April 10, 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 exhausted on date of service May 3, 2021.   
 
 
 
 
 
Specifically, the Plans contract states that one comprehensive oral evaluation is covered every three calendar 
years. You previously received this service on May 3, 2021, less than three years prior, which was paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for this service. Additionally, a full mouth or 
panoramic radiographic image is covered every five calendar years. You previously received a full mouth x-ray 
on May 3, 2021, less than five 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 
comprehensive oral evaluation (D0150) and the panoramic radiographic image (D0330) provided on April 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97124) provided from March 3, 2023, 
through April 21, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the massage therapy (97124) provided from March 3, 2023, through  
April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367), 2D oral/facial photographic images (D0350 x 4), and the intraoral-periapical additional 
radiographic images (D0230 x 5) provided on May 15, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cone beam computed tomography capture 
and interpretation and the 2D oral/facial photographic images are not covered under the supplemental dental 
policy. Additionally, you have exhausted the allowable benefit for the intraoral-periapical additional 
photographic images provided.  
 
  
 
 
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 cone beam computed tomography 
capture and interpretation and the 2D oral/facial photographic images are not among those covered under this 
benefit. Additionally, the Plan contract states that one intraoral-periapical x-ray is covered per calendar year. 
On this day, you received six intraoral-periapical x-rays, of which one x-ray 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 cone beam computed tomography (CT) capture and interpretation (D0367), 2D 
oral/facial photographic images (D0350 x 4), and the intraoral-periapical additional radiographic images 
(D0230 x 5) provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kuros MagnetOs Allograft and the Infuse BMP 
allograft (20930). 
 
You asked the Plan to pre-approve Kuros MagnetOs Allograft and the Infuse BMP allograft. 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 Kuros MagnetOs Allograft and the Infuse BMP allograft. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kuros MagnetOs Allograft and the Infuse BMP allograft4 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Kuros MagnetOs Allograft and the Infuse 
BMP allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration 
(D9610), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general anesthesia  first 15 minutes  
(D9222), and each subsequent 15 minute increment  (D9223). 
 
You asked the Plan to pre-approve the dental services represented by codes D9610, D7210, D9222, and D9223. 
The Plan denied your request. The Plan says these services are not covered by 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
parenteral drug, single administration (D9610), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general 
anesthesia  first 15 minutes  (D9222), and each subsequent 15 minute increment  (D9223).
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 301-50-0388A  The Plan denied your request. The 
Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports 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.  
 
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 a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that a resin-based denture hurts your mouth, 
and you want to try one with a flexible base. 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 a 
maxillary partial denture (D5225).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on April 6, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that you were not the one that 
called the ambulance, and you are unable to afford the cost. The Plan denied your request. The Plan says the 
ambulance benefit is a transport benefit if there is no transport, then there is no Medicare covered 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 6, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
 
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was filed timely. The Plan denied 
your request. The Plan says the claim was not filed within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until March 31, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on March 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on October 
18, 2022. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were not aware that 
the services would not be covered. The Plan denied your request. The Plan says the Medicare ambulance 
benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic and retainer crown (D6740, D6245) provided on 
May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a pontic 
and retainer crown (D6740, D6245) provided on May 1, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF is necessary for the enrollee to 
begin rehabilitation. The Plan denied your request. The Plan says that the enrollee's condition requires ongoing 
medical care in their current setting.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee did qualify for SNF coverage.  
The enrollee did not have documented skilled nursing needs. The enrollee did have documented skilled therapy 
needs. The enrollee was functioning below her baseline. Daily skilled services were required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care, per day (99306) provided on 
October 25, 2021. 
 
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 the service at issue is not payable as the claim 
was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until April 21, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the initial nursing facility care, per day (99306) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for evaluation and management services (procedure code 99214) rendered 
on May 1, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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, the CPT Code Manual definition of 
code 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had a new problem with 
substantial morbidity and mortality. The documentation does support a moderate level of billing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
evaluation and management services (procedure code 99214) rendered on May 1, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you have more 
appointments to attend, and you need the transportation. The Plan denied your request. The Plan says the 
routine transportation services benefit has been exhausted. 
 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 30 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 additional routine transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental anesthesia (D9222) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental anesthesia. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental anesthesia (D9222) 
provided on May 24, 2023.