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

 
We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem 
focused (D0140), pulp vitality tests (D0460), and endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided May 11, 2022. 
 
You asked the Plan to provide additional payment for the limited oral exam, pulp vitality tests and root canal. 
You say that you feel you should be reimbursed. The Plan denied your request. The Plan says you have 
exhausted your 2022 dental benefit and no further payment is due. 
 
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 limited 
oral exam, pulp vitality tests and root canal up to $1,000 annually for dental services combined.  
 We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $538 remaining in your annual dental allowance. This amount was applied towards 
your claim. You have been asked to pay the remaining amount beyond your dental allowance. This means you 
have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the 
Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), 
pulp vitality tests (D0460), and endodontic therapy, premolar tooth (excluding final restoration) (D3320) 
provided May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies. 
 
You asked the Plan to pre-approve the CGM. You say that you believe that your health condition is caused by 
low blood pressure, and you feel that your life is in danger. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
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. Your records show you are not insulin-treated with multiple (three or 
more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CGM and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional cost for dental services provided on May 5, 2022. 
 
You asked the Plan to pay an additional cost for the dental services. You say that you were given names of in-
network providers, so you do not know why you are being charged. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider; therefore, you have a 70% coinsurance 
under 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. When you receive services 
out-of-network you must pay 70% coinsurance. 
 
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 have a 70% coinsurance 
under this benefit when received from an out-of-network provider. There are nearby in-network dentists to 
choose from. Therefore, we decided that the Plan has paid the correct amount for dental services provided on 
May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2022 billed with 
code 81162. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this testing was part of a genetic testing panel and is not separately 
payable. 
 
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 
April 12, 2022 billed with code 81162.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat lift chair repairs. 
 
 
 
 
 You asked the Plan to pre-approve power seat lift chair repairs. You say that you explained about past events 
that have happened years ago that are becoming an issue to why you cannot get your chair. The Plan denied 
your request. The Plan says an evaluation dated 5-19-2022 notes that you have two lift chairs in a small room 
that is filled with things that limited the movement of the chairs. There was evidence that water had leaked 
around the chair. All electrical components and the motor require replacement. Therefore, given the provided 
documentation, you do not meet the guidelines for the requested service which does not appear medically 
necessary because you are not able to safely operate the power seat chair and there is a risk that you will injure 
yourself. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the cost of the repairs exceed the cost of the 
chair, therefore, you do not meet the criteria for approval of repairs to your power seat lift chair. Based on this 
information, we decided that Medicare rules for coverage of power seat lift chair repairs have not been met. 
Therefore, we decided that the Plan does not have to pre-approve power seat lift chair repairs.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a CPAP and humidifier (E0562, E0601). 
 
You asked the Plan to pre-approve a CPAP and humidifier. You say that the enrollee has severe underlying 
tracheobronchomalacia and in a January 2022 sleep study she had an AHI of 4.3 consistent with mild 
obstructive sleep apnea. The enrollee was noted to have a respiratory disturbance index of greater than 15, thus 
auto-titrating the CPAP 6-15 was recommended by the interpreting sleep provider. The Plan denied your 
request. The Plan says that the enrollee does not have either daytime sleepiness or any of the conditions listed, 
the criteria for coverage of CPAP are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 CPAP and humidifier. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has COPD and severe tracheobronchomalacia, with frequent 
exacerbations and difficulty clearing mucus. Some of the enrollee's sensation of mucus plugging may well be 
expiratory airway collapse. A home sleep study showed RDI of 16.6, indicating OSA. A home sleep study may 
underestimate the severity of the OSA. Even though the enrollee does not have excessive daytime sleepiness or 
hypertension, treatment of the OSA with CPAP is reasonable to reduce nocturnal hypoxemia. It may also help 
sustain patency of the trachea and bronchi during sleep. 
 
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 CPAP and humidifier have been met. Therefore, we decided that the Plan has 
to pre-approve a CPAP and humidifier (E0562, E0601).  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Health Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
partial mandibular denture (D5214) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigations (D4921) provided on October 7, 2021 
 
You asked the Plan to pay for the dental services. You say that you were told from the provider that medical 
necessity documentation would be submitted to the Plan and be covered. The Plan denied your request. The 
Plan says gingival irrigation (D4921) is not covered under 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. 
 
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 
gingival irrigations (D4921) provided on October 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150), an intraoral periapical 
x-ray (D0220), and a porcelain/ceramic crown on tooth #13 (D2740) provided by an out-of-network provider 
on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that your insurance is 
not accepted by the provider until after the procedures were completed. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral exam (D0150), an intraoral periapical x-ray (D0220), and a porcelain/ceramic 
crown on tooth #13 (D2740) provided by an out-of-network provider on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of hyperplastic tissue (D7970) provided by 
a participating provider. 
 
You asked the Plan to pre-approve an excision of hyperplastic tissue. You say that you have extra tissue on 
your lower gum line. You say that these services are medically necessary. The Plan denied your request. The 
Plan says the requested dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
excision of hyperplastic tissue (D7970) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lipoprotein, direct measurement; high density 
cholesterol (HDL cholesterol) lab test provided to the enrollee on March 28, 2022. 
 You asked the Plan to pay for these services. You say that the enrollee could not control where the tests were 
performed. The Plan denied your request. The Plan says that this denied because it is bundled to another 
service billed on the same day. 
 
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, we have confirmed that code 83718 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the Lipoprotein, direct measurement; high density cholesterol (HDL 
cholesterol) lab test provided to the enrollee on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pre-approve a crown for tooth #3 (codes D2740 and D2950) and periodontal scaling/root 
planing in all 4 quadrants of the mouth (code D4341 in each quadrant). You say that you are appealing with 
supporting records. The Plan says that the requested crown is not covered by the Plan and the periodontal 
scaling/root planing is not medically necessary.  We decided that the Plan has to pre-approve periodontal scaling/root planing in all 4 quadrants.  
 
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/root planing 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/root planing. Our 
reviewer says that the requested periodontal scaling/root planing in all 4 quadrants of the mouth is medically 
necessary for the enrollee. Our physician reviewer found the documentation reviewed indicates the presence of 
4 to 5 millimeter periodontal pockets in all quadrants, areas of subgingival calculus, and areas of bone loss. 
Periodontal scaling and root planing is medically reasonable and necessary to treat the enrollee's periodontal 
disease. 
 
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/root planing have been met. Therefore, we decided that the 
Plan has to pre-approve periodontal scaling/root planing.  
 
We also decided that the Plan does not have to pre-approve a crown for tooth #3. 
 
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 crown is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown for 
tooth #3. 
 
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 a total electric hospital bed (E0266). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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. Your request is not medically necessary because your records show 
you do not have diabetes. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 11, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a 
participating provider on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentures you received are uncomfortable. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by a 
participating provider on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth (D7210) provided on 
January 8, 2022, and two porcelain/ceramic retainer crowns (D6740) and a porcelain/ceramic pontic (D6245) 
provided on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not able to call the Plan before 
receiving the services to verify if the services were a covered benefit. The Plan denied your request. The Plan 
says the claim was processed correctly. According to your contract with the Plan, the services rendered are 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 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 
extraction of an erupted tooth (D7210) provided on January 8, 2022, and two porcelain/ceramic retainer crowns 
(D6740) and a porcelain/ceramic pontic (D6245) provided on April 11, 2022.