Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor knee and advanced foot/ankle with 
additional features (L5828, L5845, L5848, L5850, L5856, L5925, L5968, L5981) including a protective outer 
covering (L5964). 
 
You asked the Plan to pre-approve a microprocessor knee and advanced foot/ankle with additional features. 
You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The 
Plan says medical necessity rules for coverage of the requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a microprocessor knee and advanced 
foot/ankle with additional features. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee's daily activities and the 
physician medical progress report do not support that the enrollee is a K3 ambulator with vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion; therefore, the 
microprocessor knee and advanced foot/ankle are not medically necessary. The documentation does not reveal 
that the enrollee is exposed to harsh environmental conditions; therefore, the feature coded L5964 exceeds the 
enrollee's medical needs. 
 
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 microprocessor knee and advanced foot/ankle with additional features have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor knee and 
advanced foot/ankle with additional features (L5828, L5845, L5848, L5850, L5856, L5925, L5968, L5981) 
including a protective outer covering (L5964).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided on April 23, 2020.
You asked the Plan to pay for the diabetic supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these items were not the Plan's preferred diabetic equipment.
The Plan must follow Medicare rules. Medicare rules say that the Plan has specific rules regarding their preferred brands that must be followed. We looked at the file and Medicare rules. In this case, no argument was presented as to why the Plan's preferred brand would not have been suitable for the enrollee. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for sleep apnea to be rendered by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the oral appliance for sleep apnea to be rendered by an OON provider. You 
say that you were referred to this OON provider because they knew he could help you based on your issues. 
The Plan denied your request. The Plan says you would like this service to be rendered by an OON provider. 
The Plan also says that there are in-network providers available to treat your condition, and the missing teeth 
would not be an issue in fitting you for an oral appliance for sleep apnea. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve an oral 
appliance for sleep apnea to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751). 
 
You asked the Plan to pre-approve the dental service. You say that you need a bridge. You say that when you 
eat, food gets stuck there. You say that you do not want to get an infection there. You say that you need a 
bridge for teeth # 8, 9, and 10. The Plan denied your request. The Plan says retainer crown is covered once 
every 60 months. The Plan also says that the frequency limit has been reached. 
 
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 and retainer crowns are listed as 
covered, the frequency limit of once every 60 months has been reached. The record shows that the Plan paid for 
retainer crowns you received on April 21, 2021. Therefore, we decided that the Plan does not have to pre-
approve a retainer crown (D6751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on November 30, 2021. 
 
You asked the Plan to pay for the core buildup. You say that you cannot pay for this procedure. 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 core 
buildup, including any pins when required (D2950) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental care provided from July 7, 2021, to August 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that this provider was able to provide certain care 
geared toward a medical condition which is not available in the Plan's network. The Plan denied your request. 
The Plan says the provider in this case is not part of the Plan's network. In addition, not all of the services 
rendered are covered by your dental benefit, regardless of the participation status of the provider. 
 
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. Services and codes not listed 
in the Plan's dental benefits chart are not covered. Services received from a non-network dentist are not 
covered. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from an out-
of-network provider are not among those covered under this benefit. The provider in this case is not part of the 
Plan's network. In addition, not all of the services provided are among those listed as eligible for coverage 
under your dental benefit. Therefore, we decided that the Plan does not have to pay for the dental care provided 
from July 7, 2021, to August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) provided 
October 11, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you were told you would be covered 100% 
for the deep cleaning. 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 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 
gingival irrigation - per quadrant (D4921) provided October 11, 2021.  
Your complaint about potentially being provided misinformation by a plan representative 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 comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on November 1, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you moved, and this treating provider was the only dentist in-network. You also say that you needed 
the x-rays to proceed with the dental care, and could not get old x-rays from your previous dentist. The Plan 
denied your request. The Plan says these services exceed the frequency limitations 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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on July 28, 2020 and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier (D4266), 
guided tissue regeneration - nonresorbable barrier (D4267), bone replacement grafts for ridge preservation 
(D7953), and drugs or medicaments dispensed in the office for home use (D9630) provided on November 9, 
2021. 
 
You asked the Plan to pay for the guided tissue regenerations, bone replacement grafts, and drugs or 
medicaments. You say that these services were provided in conjuncture with tooth extractions (D7210) and you 
feel some of these services should be coded differently. You also say that the medication that was dispensed 
should be covered. 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 
guided tissue regeneration - resorbable barrier (D4266), guided tissue regeneration - nonresorbable barrier 
(D4267), bone replacement grafts for ridge preservation (D7953), and drugs or medicaments dispensed in the 
office for home use (D9630) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable endoskeletal system (L5920). 
 
You asked the Plan to pre-approve an alignable endoskeletal system. You say that the requested additional 
prosthetic equipment is medically reasonable and necessary. The Plan denied your request. The Plan says this 
is not medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an alignable endoskeletal system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 78-year-old male with the diagnosis of acquired absence of 
left leg above knee. The patient was approved for a preparatory prosthesis (L5590) in January 2022 and resides 
in a two-story home with stairs at entry and bedroom/bathroom on the second floor. In this case, the approved L5590 preparatory prosthesis is a non-alignable system and therefore the L5920 alignable system cannot be used with this preparatory prosthesis. The requested alignable system is found at this time to exceed the patient's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an alignable endoskeletal system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an alignable endoskeletal system (L5920).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130), mandibular 
immediate denture (D5140), surgical placement of implant body: endosteal implants (D6010), simple 
extractions (D7140), and alveoloplasties in conjunction with extractions (D7310) provided on November 8, 
2021. 
 
You asked the Plan to pay for the maxillary immediate denture, mandibular immediate denture, endosteal 
implants, simple extractions, and alveoloplasties. You say that you had a disease in your teeth which caused 
trouble for your heart. You also say that your dentist advised that with as much bacteria as you had in your 
mouth could cause trouble with your heart and allow bacteria into your body. The Plan denied your request. 
The Plan says you do not have a supplemental benefit for dental services. The Plan also says that these services 
are not covered by Medicare. 
 
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 maxillary immediate denture 
(D5130), mandibular immediate denture (D5140), surgical placement of implant body: endosteal implants 
(D6010), simple extractions (D7140), and alveoloplasties in conjunction with extractions (D7310) provided on 
November 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional skilled nursing visits in your home. 
You asked the Plan to pre-approve 10 additional skilled nursing visits in home. You say that you need 
additional wound care. The Plan denied your request. The Plan says the additional visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 10 additional skilled nursing visits in 
home. Our reviewer says that the additional 10 PT visits in your home are not medically necessary. Our 
physician reviewer found the provided documentation indicates that the wound care being provided was not 
complex and the wound was improving. The documentation indicates that you live with family. The reviewer 
found that you are attending wound clinic appointments. As a practical matter, the quantity of requested 
services is not shown to be medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional skilled nursing visits in home have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional skilled nursing visits in your home.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable unilateral partial denture (D5283). 
 
You asked the Plan to pre-approve the dental service. You say that the requested procedure is necessary as you 
are unable to eat or bite. The Plan denied your request. The Plan says removable unilateral partial denture is not 
listed as a covered service. 
 
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 removable unilateral 
partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removable unilateral partial denture (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) 
and limited oral evaluation - problem focused (D0140) provided June 14, 2021. 
You asked the Plan to pay for the filling and limited oral exam. You say that you were unaware that the 
provider does not participate with Medicare. The Plan denied your request. The Plan says these services are not 
covered because the provider 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 Plan's coverage rules apply in this case. The Plan covers the filling and 
limited oral exam when you see any licensed dental provider who accepts Medicare patients in the United 
States and has not opted out of Original Medicare.  
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the filling and limited oral exam have not been met. Therefore, 
we decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) 
and limited oral evaluation - problem focused (D0140) provided June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided 
on November 2, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you realize the 
treating provider is OON, but you were certain the Plan would cover something. You also say that you would 
like the denial of payment to be reconsidered. The Plan denied your request. The Plan says that the total 
$100.00 OON amount applied correctly as your liability. The Plan also says that cost sharing is a contractual 
obligation under the plan and cannot be waived. 
 
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. 
 
We looked at the file and Medicare rules. There is no provision in the contract which indicates that the Plan is 
relieved of its obligation to cover services simply because another plan has made payment. Since the enrollee 
was held liable for and paid more than what the Plan pays for these Plan-covered services, the Plan is 
contractually required to reimburse the enrollee, irrespective of any payments made by another party. Based on 
this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and prophylaxis 
have been met. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on November 2, 2021 by an out-of-network (OON) provider.  
 
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 dental services provided from August 6, 2020, through 
September 30, 2020. 
 
You asked the Plan to pay for dental services. The Plan denied your request. The Plan says the claim were 
received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until December 20, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided from August 6, 2020, through September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy (D3347). 
 
You asked the Plan to pre-approve retreatment of a root canal. You say that this service is necessary. 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 pre-approve 
retreatment of previous root canal therapy (D3347).