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

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 4, 2021, and gingival flap procedure, including root planing - one to three contiguous teeth 
or tooth bounded spaces per quadrant (D4241) provided December 13, 2021. 
 
You asked the Plan to pay for the limited oral exam and gingival flap procedure. You say that the services were 
medically necessary. The Plan denied your request. The Plan says these services are not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
limited oral evaluation - problem focused (D0140) provided November 4, 2021, and gingival flap procedure, 
including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (D4241) provided 
December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the member is not insulin treated with multiple daily administrations. 
 
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 and 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 the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 9, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware 
that this procedure code could only be used once a year. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on June 30, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) 
provided on December 22, 2021. 
 
You asked the Plan to pay for the application of desensitizing medicament. You say that you feel that since you 
were a new patient, you should have been advised that services you received would not be covered. The Plan 
denied your request. The Plan says this service is not a covered expense 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 pay for the 
application of desensitizing medicament (D9910) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 24, 
2021, by an opt out provider. 
 
You asked the Plan to pay for the dental service. You say that you opted out of Medicare in 2007. You say that 
you are now receiving notification that your patient's reimbursements are being negatively affected. You also 
say that an exception should be made. The Plan denied your request. The Plan says payment cannot be made to 
a provider that has opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 24, 2021, by an 
opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) sensors 
(K0553). 
 
You asked the Plan to pre-approve the CGM sensors. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you are not insulin treated. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) sensors (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral formula (B1402). 
 
You asked the Plan to pre-approve the enteral formula. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the enteral formula (B1402).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided to the enrollee on August 13, 2021. 
 
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 this was billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. They have not stated what the 
appropriate place of service would be in this case. Therefore, we decided that the Plan has to pay for imaging 
services provided to the enrollee on August 13, 2021.  
 
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 pay for the intraoral - periapical each additional radiographic image 
(D0230) provided November 23, 2021. 
 
You asked the Plan to pay for the additional intraoral x-ray. You say that the extra x-ray was necessary for your 
dental care. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral 
x-ray per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray 
was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit 
for coverage of the additional intraoral x-ray has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the intraoral - periapical each additional radiographic image (D0230) provided November 23, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for a radiologic examination, mandible; partial, less than four views 
(70100). We decided that the Plan does not have to pay for a radiologic examination, gastrointestinal tract, 
upper (74240), an X-ray of spine and neck (72040), and an X-ray of teeth (70310).  
 
You asked the Plan to pay for multiple radiology procedures. The Plan says that multiple radiology procedures 
are not medically necessary. 
 
We decided that the Plan has to pay for a radiologic examination, mandible; partial, less than four views 
(70100).  
 
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 multiple radiology procedures. Our reviewer says that a radiologic 
examination, mandible; partial, less than four views (70100) is medically necessary. Our reviewer found that 
the 2 view mandible series makes sense. Therefore, we decided that the Plan has to pay for a radiologic 
examination, mandible; partial, less than four views (70100). 
 
We also decided that the Plan does not have to pay for a radiologic examination, mandible; partial, less 
than four views (70100). Therefore, we decided that the Plan does not have to pay for a radiologic 
examination, gastrointestinal tract, upper (74240), an X-ray of spine and neck (72040), and an X-ray of teeth 
(70310).  
 
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 multiple radiology procedures. Our reviewer says that a radiologic 
examination, gastrointestinal tract, upper (74240), an X-ray of spine and neck (72040), and an X-ray of teeth 
(70310) is not medically reasonable and necessary. Our reviewer found that a modified barium swallow was 
performed, which was appropriate for a patient with dysphagia however the exam done was C but the 2-view 
neck, soft tissue was coded 74290 (UGI) which was incorrect. The exam should have been coded as 
74230. The 2 view C spine series was unnecessary as the information desired would have been visible on the 
2-view cervical spine series. The views of the teeth were unnecessary. Therefore, we decided that the Plan does 
not have to pay for a radiologic examination, gastrointestinal tract, upper (74240), an X-ray of spine and neck 
(72040), and an X-ray of teeth (70310).  
 
 
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 pay for the limited (problem focused) oral exam (D0140) provided 
on November 18, 2021. 
 
You asked the Plan to pay for the limited exam. You say that you feel this bill is wrong and you already paid 
some amount at the dentist's office. The Plan denied your request. The Plan says this service is not covered by 
your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited (problem focused) oral exam (D0140) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) and pulp 
vitality tests (D0460) provided June 7, 2021. 
 
You asked the Plan to pay for the bitewing x-rays and pulp vitality tests. You say that you were not informed 
about frequency limits prior to the services. The Plan denied your request. The Plan says you have exceeded 
the frequency limit for bitewing x-rays and the pulp vitality test is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the bitewing 
x-rays once per plan year.  
 
We looked at the file and Medicare rules. The Plan provide documentation showing that bitewing x-rays were 
covered on November 11, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the pulp vitality test is not among those covered services. Therefore, we decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) and pulp vitality tests (D0460) provided June 7, 2021.  
 
Your complaint about not feeling adequately informed of the frequency limit is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income and do not have the 
money to pay this bill. You say that the procedure was an emergency and you proceeded not knowing you had 
exhausted your benefit. The Plan denied your request. The Plan says after the maximum benefit allowed is 
exhausted, any remaining charges are your responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
$2,500 for dental services in the 2021 plan year. The Plan paid $2,500 toward dental services prior to receiving 
these services. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bitewings - four radiographic images (D0274) provided October 19, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were given incorrect information about 
your coverage for fillings, and bitewing x-rays should have a $0 copayment. The Plan denied your request. The 
Plan says that your claims have been reprocessed due to incorrect information provided to you, however you 
have exceeded the frequency limit for bitewing x-rays 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that 
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
bitewing x-rays once per calendar year. 
 
We looked at the file and Medicare rules. In this case the Plan has denied the bitewing x-rays on the basis that 
the frequency limit has been exceeded. However, the Plan has failed to provide any documentation to show that 
coverage was previously provided. Without the previous claims information, we are unable to verify that the 
Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the 
Plan has to pay for the bitewings - four radiographic images (D0274) provided October 19, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically 
necessary. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a skilled nursing facility (SNF) stay provided from 
August 1, 2021, to August 16, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that while your extension of service was 
approved you were never made aware that you would be responsible for $178 daily. You also say you are on a 
fixed income and are unable to pay $2,670. The Plan denied your request. The Plan says that you have been 
charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide records showing the complete length of your stay at the 
skilled nursing facility. Without having the records, we are unable to determine if the cost sharing applied is 
correct. Therefore, we decided that the Plan has to waive the copayment for a skilled nursing facility (SNF) 
stay provided from August 1, 2021, to August 16, 2021.  
 
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 pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided December 28, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that extractions are covered, and you should 
have full coverage. The Plan denied your request. The Plan says this service is not covered under your 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 2) and pontics (D6240 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot chew properly due to missing 
front teeth. You also say that you do not agree with the denial. The Plan denied your request. The Plan says the 
maximum benefit of $1,000 has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum benefit of $1,000 has 
been exhausted. The record shows that the Plan approved 2 retainer crowns in the amount of $465 each, and a 
pontic in the amount of $70. $465 + $465 + $70 = $1,000. Therefore, we decided that the Plan does not have to 
pre-approve retainer crowns (D6750 x 2) and pontics (D6240 x 2).