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

 
We decided that the Plan does not have to pre-approve a maxillary denture (D5110) 
 
You asked the Plan to pre-approve the maxillary denture. 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 were 
non-emergent and prior authorization was not obtained. 
 
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 denture (D5110)
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered prepared meals (S5170). 
 
You asked the Plan to pre-approve the prepared meals. You say that you had a hip replacement operation which 
prevents you from being able to fend for yourself. You live alone and is dependent on home care, so you do not 
help preparing food. The Plan denied your request. The Plan says the enrollee does not have a qualifying 
chronic condition to meet the Plan's criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the prepared meals have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve home delivered prepared meals (S5170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on November 23, 2021. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation (D7953). You say that the 
procedure was medical due to a disease in your mouth. You say you should be reimbursed for the claim. The 
Plan denied your request. The Plan says the procedure code is not payable. 
 
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 the bone replacement graft for 
ridge preservation (D7953) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional dental services provided on December 17, 
2021. 
 
You asked the Plan to pay for the dental services. You say that the Plan still owes you $1,000. The Plan denied 
your request. The Plan says your dental allowance 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 dental allowance was exhausted on date of service December 17, 2021. Therefore, we decided that 
the Plan does not have to pay for the additional dental services provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on June 15, 
2022. 
 
You asked the Plan to pay for the oral hygiene instructions. You say that you were told that you were covered 
up to $500 per year with a $0 deductible for cleanings. The Plan denied your request. The Plan says this service 
is not covered under 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 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 oral 
hygiene instructions (D1330) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and 
preventive procedure (D1999) provided on April 7, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and preventive procedure. You say 
that you would like to appeal these services. The Plan denied your request. The Plan says these services are not 
covered benefits 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 
comprehensive periodontal evaluation (D0180) and preventive procedure (D1999) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on April 27, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says separate payment cannot be made for these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluations (D0140) 
provided from May 31, 2022, to June 14, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluations. You say that you do not think you 
received oral evaluations each time you were called back to put the resin on top of your teeth. The Plan denied 
your request. The Plan says this service is not covered under the 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 
problem focused limited oral evaluations (D0140) provided from May 31, 2022, to June 14, 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 intraoral-
complete series of radiographic images (D0210) provided on August 1, 2022. 
 
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 December 15, 2020. 
Specifically, the Plan contract says that a comprehensive oral evaluation is covered once every three years. 
Additionally, an intraoral-complete series of radiographic images is covered once every five years.  You previously received these services on December 15, 2020, which were paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator (E2300), an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), a harness for upgrade to 
expandable controller (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that you disagree with the denial 
and are requesting reconsideration of equipment that was already previously approved. The Plan denied your 
request. The Plan says a seat elevator does not serve a primary medical purpose and is statutorily  
non-covered. The Plan also says although there are three approved power options/features on this wheelchair 
(tilt, recline, and elevating leg rests), there is not a medical need to control these power options/features 
through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The seat elevator does not serve a purpose that is primarily medical in nature. This item is available to the 
general public and would be helpful even to those who are not sick or injured. The records show that the 
remaining accessories do not serve a medical need to control these power options/features through the joystick. 
Therefore, we decided that the Plan does not have to pre-approve a seat elevator (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to expandable controller (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of procedure code 88305 billed for date of service 
October 22, 2021. 
 
You asked the Plan to pay for 2 units of procedure code 88305. You say that you have provided records to 
support the code at issue. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 21, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for 2 units of procedure code 88305 have not 
been met. Therefore, we decided that the Plan does not have to pay for 2 units of procedure code 88305 billed 
for date of service October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial maxillary denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your top denture in a physical 
altercation. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a partial maxillary denture (D5213).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81455) provided on February 10, 2022. 
 
You asked the Plan to pre-approve the genetic testing. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. The code billed was non-covered as of the date of service under 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81455) 
provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg with an advanced knee and foot features 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve orthotics. You say that you are requesting GAP exception for prosthetic. 
The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
prosthetic leg with an advanced knee and foot features to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic eye examination to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a diagnostic eye examination. You say that the permanent damage to the 
member's brain and optic nerves warrants eye care with someone who is specialized in treating neurological 
conditions that negatively impact the visual system. The Plan denied your request. The Plan says out-of-
network providers, such as the specialist requested, must agree to submit records for prior authorization, bill the 
medical group, and wait for payment at Medicare rates. The Plan also says that the requested provider is not 
willing to accept the authorization and abide by the billing rules. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a diagnostic eye examination to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) provided on May 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that these dental codes are covered. The Plan denied 
your request. The Plan says these services are not covered by the Plan's 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 the 
intraoral x-rays (D0220 and D0230) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on December 6, 2021.

You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to Pay for this. 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 28, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date of service December 23, 2021.

You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for codes G0481 and 80307; however, code 83789 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date of service December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110), surgical placement of implant body: endosteal implant tooth 4 (D6010), 
surgical access to an implant body tooth 4 (D6011), precision attachment tooth 4 (D6950), and surgical access 
to an implant body tooth 4 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that you need a replacement and upgrade to 
what started seven years ago through your benefits. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 
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 
implant /abutment supported removable denture for edentulous arch  maxillary (D6110), surgical placement 
of implant body: endosteal implant tooth 4 (D6010), surgical access to an implant body tooth 4 (D6011), 
precision attachment  tooth 4 (D6950), and surgical access to an implant body tooth 4 (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies to be 
provided by an OON provider. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. The Plan denied your request. 
The Plan says this provider is not part of the Plan's preferred network. These services can be received by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor and supplies to be provided by an OON provider.