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

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the likelihood of greater issues with your dental 
health will occur if this service is not covered. 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 April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on July 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy; initial assessment and 
intervention, individual, face-to-face with the patient, each 15 minutes (97802) provided January 21, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are submitting medical 
records to support medical necessity. Please review and process your claim for payment. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy; initial assessment and intervention, individual, 
face-to-face with the patient, each 15 minutes (97802) provided January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intra-oral x-ray (D0150, 
D0210) provided on May 31, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 December 10, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and intra-oral x-
ray (D0150, D0210) provided on May 31, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided by an out-of-network provider on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were an emergency. 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 complete maxillary and mandibular denture (D5110 and D5120) provided by an out-of-network 
provider on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic testing strips. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve diabetic testing strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 3, 2022, billed with code 
81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
June 3, 2022, billed with code 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you assumed the office would have run a check 
on your coverage before proceeding with making your dentures. 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 20, 2020. Therefore, we decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a resin-based composite on tooth #10 
(D2331) and a resin-based composite on tooth #2 (D2392) provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that you should only be 
responsible for $145 but you are being charged the full amount. The Plan denied your request. The Plan says 
this cost sharing was charged correctly.  
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 are not covered 
when done for cosmetic reasons. You are responsible for the full amount the provider charged for the filling on 
tooth #2 because the records show that it was performed for cosmetic purposes. This means the cost-share has 
been applied correctly.  Therefore, we decided that the Plan does not have to waive the copayment for a resin-
based composite on tooth #10 (D2331) and a resin-based composite on tooth #2 (D2392) provided on May 17, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care.  Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee is medically stable. The document does not 
support medical necessity for admission to an IRF. There are no complex nursing or rehabilitation needs. While 
the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you say that on July 26, 2022, you went to a 
dentist office for a bad toothache. You also say that the provider said you needed a root canal, which he does 
not do, so he referred you to this provider. 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 July 26, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 March 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation, extraction, and a 
bone replacement graft (D0180, D7210, D7953) provided on June 29, 2022 to August 16, 2022. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation, extraction, and a bone replacement graft (D0180, D7210, D7953) 
provided on June 29, 2022 to August 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not, as prescribed, among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Prolia.  
 
  Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the evaluation from the 
therapist clearly shows and demonstrates the need for the power tilt mechanism. 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 must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Difelikefalin injections (J0879) 2 times a week while in 
Puerto Rico. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee was diagnosed with renal failure 
and requires outpatient dialysis as a life sustaining treatment The Plan denied your request. The Plan says the 
documentation does not establish the medical necessity for the services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the Difelikefalin at issue 
in this case meets all Medicare criteria for medically reasonable and necessary and is safe and effective for the 
enrollee. Provided records do not document hemodialysis-associated pruritus (Moderate to Severe) as is 
required for use of this drug. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Difelikefalin injections (J0879) 2 times a week while in Puerto Rico.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and intraoral - complete series of radiographic images (D0210) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you had already utilized 
the exhausted benefits. 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 March 29, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and intraoral - complete series of radiographic images (D0210) provided on 
August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210) provided by a participating provider on 
July 7, 2022. 
 
You asked the Plan to pay for extractions. You say that you needed these services. The Plan denied your 
request. The Plan says the enrollee only has preventative dental coverage. 
 
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 
extractions (D7210) provided by a participating provider on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve CardioMEMS device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. Our physician reviewer 
found that, at this time, the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees clinical management. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor 
(CardioMEMS) (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in extreme pain. 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 May 9, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt seating system (E1002) for a power 
wheelchair.  
You asked the Plan to pre-approve a power tilt seating system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 power tilt seating system. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available documentation does not indicate that the enrollee has any pressure 
injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or recline. 
 
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 power tilt seating system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power tilt seating system (E1002) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D7921, D6010, D6056, D4266) 
 
You asked the Plan to pre-approve the dental services. 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 do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D7921, D6010, D6056, D4266)