Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested procedure is covered by 
Medicare and is medically necessary for this enrollee. The Plan denied your request. The Plan says the request 
is not medically necessary because the records show that the enrollee has not been evaluated by a surgical 
team. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column and depth brain stimulators are only 
covered for certain indications.  
 
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 spinal cord stimulator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found detailed documentation is 
not evident regarding the requested spinal cord stimulator being a late/last resort for this enrollee. She was 
recommended to undergo physical therapy on the September 21, 2022, exam. Additionally, during that exam, 
she was noted to have a surgical follow-up/referral. The requested spinal cord stimulator is not potentially 
indicated until she has been deemed to not be a surgical candidate. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for a therapeutic continuous glucose 
monitor (CGM) and receiver (K0553, K0554). 
 
You asked the Plan to pre-approve a supply allowance for a CGM and receiver. You say that the enrollee needs 
the machine as she has not been able to keep her blood sugar under control. Medical records have been 
submitted to show necessity. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for approval of the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a supply 
allowance for a CGM and receiver have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a supply allowance for a therapeutic continuous glucose monitor (CGM) and receiver (K0553, 
K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), bitewing x-ray (D0274), prophylaxis (D1110), and topical application of fluoride (D1208) provided 
on June 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these dental 
services were received from an OON 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 OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), panoramic x-ray (D0330), bitewing x-ray (D0274), prophylaxis 
(D1110), and topical application of fluoride (D1208) provided on June 27, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331), a porcelain/ceramic crown 
(D2740), and a core buildup (D2950) provided on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not have had the services if they 
were not covered by insurance. You say you never received the Annual Notice of Change document from the 
Plan. The Plan denied your request. The Plan says your benefit for the crown and resin-based composite has 
already been exhausted. The Plan also says that the core buildup is not a covered benefit. According to the 
Plans documentation, the Annual Notice of Change was mailed to you on September 13, 2021. 
 
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 annual maximum of $1,000 was exhausted on the date of service in the amount of $471. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite (D2331), a porcelain/ceramic crown 
(D2740), and a core buildup (D2950) provided on June 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 10, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the surgical services were a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment for self-administered drugs 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here have not been billed as drugs that are among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for 
self-administered drugs provided on May 10, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns on tooth #20, 21, and 22 (D2751). 
 
You asked the Plan to pre-approve crowns. You say that you want the crowns covered. The Plan denied your 
request. The Plan says the requested teeth do not appear to have significant breakdown due to decay or trauma. 
 
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 crowns when 
the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that a review of the documentation indicates 
that there does not appear to be significant coronal breakdown due to caries or fracture to warrant crown 
restorations for teeth #'s 20, 21, and 22. 
 
 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 crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve crowns on tooth #20, 21, and 22 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite fillings on tooth #28 and 29 (D2391) 
provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the fillings were medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested items or 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 requested items or services was exhausted on date of service March 29, 2022, and 
June 22, 2022. Therefore, we decided that the Plan does not have to pay for resin-based composite fillings on 
tooth #28 and 29 (D2391) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) and 
therapeutic parenteral drugs such as antibiotics, steroids, anti-inflammatory drugs, or other therapeutic 
medications (D9612) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed for part of the 
services rendered to you. The Plan denied your request. The Plan says the services at issue are not covered 
under 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 bone 
replacement graft for ridge preservation (D7953) and therapeutic parenteral drugs such as antibiotics, steroids, 
anti-inflammatory drugs, or other therapeutic medications (D9612) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve a partial denture. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a partial mandibular denture (D5214) is not covered by 
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 pre-approve a 
partial mandibular denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 6, 2021 billed with 
codes 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 6, 2021 billed with codes 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 81321.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing service provided on January 27, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic testing service. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 diagnostic testing service provided on January 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist visit on June 8, 2022. 
 
You asked the Plan to reduce the copayment for a specialist visit. You say that you should only be responsible 
to pay $5 because you were seen by a nurse practitioner and not the doctor. 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 $40 
copayment for a specialist visit.  
 
You have been asked to pay $40 for a specialist visit. This item/service falls within the specialist visit benefit 
category. The records show you were seen at a pain management office, which is considered a specialist. 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 reduce the copayment for a specialist visit on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the impacted tooth removal (D2740). 
 
You asked the Plan to pre-approve impacted tooth removal (D2740). You say that you are appealing the denial. 
The Plan denied your request. The Plan says the 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 impacted tooth removal (D2740) 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the impacted tooth removal (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), resin-
based composite - one surface, anterior (D2330) and endodontic therapy, anterior tooth (excluding final 
restoration) (D3310). 
 
You asked the Plan to pay for dental services. You say that you needed these services due to a fall. The Plan 
denied your request. The Plan says this service is 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. Intraoral - periapical first 
radiographic image and endodontic therapy, anterior tooth (excluding final restoration) are not covered under 
the Plans dental benefits. Resin-based composite - one surface, anterior is a covered benefit with a limitation 
of 2 procedure codes per calendar year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested intraoral - periapical first 
radiographic image (D0220) and endodontic therapy, anterior tooth (excluding final restoration) (D3310) are 
not among those covered under this benefit. The record shows your benefit for the requested resin-based 
composite - one surface, anterior (D2330) was provided on April 25, 2022, and June 1, 2022. Therefore, this 
benefit was exhausted on June 1, 2022. Therefore, we decided that the Plan does not have to pay for intraoral - 
periapical first radiographic image (D0220), resin-based composite - one surface, anterior (D2330) and 
endodontic therapy, anterior tooth (excluding final restoration) (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), and drugs or 
medicament dispensed in office for home use (D9630). 
 
You asked the Plan to pre-approve a bone replacement graft, and drugs or medicament dispensed in office for 
home use. You say that the services are necessary, and you want the Plan to cover them. The Plan denied your 
request. The Plan says the services at issue 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 a 
bone replacement graft (D4263), and drugs or medicament dispensed in office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the upper right 
quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that this service is medically necessary. The 
Plan denied your request. The Plan says a minimum of four affected teeth be present in the quadrant to qualify 
for this 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. The Plan covers periodontal 
scaling when the services are medically necessary and reasonable.  
 
 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 periodontal scaling. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the documentation provided does 
not meet the criteria for coverage for periodontal scaling and root planing, four or more teeth (D4341) in the 
upper right quadrant. There are only three teeth that appear to be present. 
 
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 periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in the upper right quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and to pay 
more for the resin-based composite (D2393) on tooth #28 provided on June 24, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays or pay more for the resin-based composite. 
You say that you would like to appeal these services. The Plan denied your request. The Plan says the complete 
series of intraoral x-rays exceeds the frequency limitations under your plan. The Plan also says that benefits 
have been paid on the least costly method of treatment for the resin-based composite, and you are responsible 
for the difference between the allowed amounts. 
 
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, intraoral x-rays of the entire mouth are 
covered once every 60 months. The record shows that you received a complete series of intraoral x-rays 
(D0210) on June 22, 2020, and your intraoral x-rays of the entire mouth benefit has been exhausted. The 
contract also clearly states that white fillings on posterior teeth will be processed as a silver filling, and you are 
responsible for up to the contracted fee. The record shows that you received a resin-based composite (filling) 
on tooth #28, which is a posterior tooth. This procedure was processed as a silver filling, and you are 
responsible for the difference. Therefore, we decided that the Plan does not have to pay for the complete series 
of intraoral x-rays (D0210) and to pay more for the resin-based composite (D2393) on tooth #28 provided on 
June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services on April 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental services on April 21, 2022.