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

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on October 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider elected to only do bitewings and it 
should be covered under your dental benefits. The Plan denied your request. The Plan says the denial of 
payment for this service is correct because bitewings are not covered by the Plan. Also, prior to the date of 
service the enrollee exhausted their yearly maximum dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bitewings 
(D0274) provided on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) and supplies provided on June 
27, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that the enrollee's physician ordered the CGM 
and supplies. The Plan denied your request. The Plan says that the proper documentation was not received; 
therefore, the criteria for the CGM were not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM and supplies. Our reviewer says 
that the CGM and supplies are medically necessary. Our physician reviewer found that the enrollee is on 
multiple daily injections with Tresiba and NovoLog. The enrollee uses a correction scale suggesting that they 
are adjusting the doses of NovoLog based on the blood glucose level at each meal. 
 
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 CGM and supplies have been met. Therefore, we decided that the Plan has 
to pay for a continuous glucose monitor (CGM) and supplies provided on June 27, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 8, 
2022. 
 You asked the Plan to pay for procedure code 99214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99214 is bundled into 
payment for code 12011. 
 
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 99214 
is a column II code to column I code 12011. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 billed for date of service September 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 25, 
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 October 13, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the extraction of an 
erupted tooth (D7210), a porcelain/ceramic crown (D2740), and core buildup (D2950) provider on August 10, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the dentist office that 
you had 100% coverage, and that is why you let them work on your mouth. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the 
extraction of an erupted tooth (D7210), a porcelain/ceramic crown (D2740), and core buildup (D2950) provider 
on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (cgm) (K0553) 
provided on March 13, 2022. 
 
You asked the Plan to pay for the CGM. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the 
shipping date or the date or delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the delivery and shipping date does not 
match the date of service March 13, 2022. Therefore, we decided that the Plan does not have to pay for a 
therapeutic continuous glucose monitor (cgm) (K0553) provided on March 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 26, 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 the services requested are not covered 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 dental 
services on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an anesthesia service provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an anesthesia service. You say that it is the responsibility of the facility to obtain 
a preauthorization for the service provided. The Plan denied your request. The Plan says there is no 
authorization on file for the services rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an anesthesia service provided on February 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polarization (V2762), polycarbonate lenses (V2784) and 
progressive lenses (V2781) provided on September 20, 2022. 
 
You asked the Plan to pay for polarization (V2762), polycarbonate lenses (V2784) and progressive lenses 
(V2781). You say that you went to a vision facility in-network to purchase new eyeglasses. You also say you 
were told they would be covered. The Plan denied your request. The Plan says your vision benefits lens 
enhancements are not covered by the plan but are offered at a discounted rate. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The lens enhancements are not covered through the allowance, but may be purchased at an additional 
cost. This includes polarization (V2762), polycarbonate lenses (V2784) and progressive lenses (V2781). 
 
We looked at the file and the Plan's rules. The Plan rules say that enhancements including polarization 
(V2762), polycarbonate lenses (V2784) and progressive lenses (V2781) are not covered through the allowance, 
but may be purchased by you at an additional cost. Based on this information, we decided that the Plan's rules 
for coverage of polarization (V2762), polycarbonate lenses (V2784) and progressive lenses (V2781) have not 
been met. Therefore, we decided that the Plan does not have to pay for polarization (V2762), polycarbonate 
lenses (V2784) and progressive lenses (V2781) provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) and implant removal 
(D6100) provided on September 12, 2022. 
 
You asked the Plan to pay for a diagnostic consultation (D9310) and implant removal (D6100). You say that 
you believe that the removal of your dental implant is a standard service and should be covered. The Plan 
denied your request. The Plan says the service provided is not a covered benefit 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 a 
diagnostic consultation (D9310) and implant removal (D6100) provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on September 15, 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 crown 
and core buildup services (D2740, D2950) provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) and a periodic oral evaluation 
(D0120) provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you obtained a copy of the primary insurers 
payment information and requested payment for the remaining balance for dental services received. 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 31, 2022. 
Therefore, we decided that the Plan does not have to pay for an adult prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. You can receive further services at a lower level of care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation, periodontal maintenance, and a 
crown (D0120, D2750, D4910) provided on August 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 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 periodic 
oral evaluation, periodontal maintenance, and a crown (D0120, D2750, D4910) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, and a 
cleaning (D0274, D1110, D0120) provided on October 10, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, 
and a cleaning (D0274, D1110, D0120) provided on October 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 2, 2022, to May 
31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
correctly. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the from date of care reported on the NOA does not 
correspond with the admission date reported on the NOA. Based on this information, we find that the Medicare 
rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from May 2, 2022, to May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, bone replacement graft, and biologic materials 
(D7210, D4263, D4265) provided on July 22, 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 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 an extraction, bone replacement graft, and biologic materials (D7210, D4263, D4265) provided on 
July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180), and intraoral - complete series of radiographic images (D0210) provided on September 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration as you only 
have 8 teeth on the bottom of your mouth. You also say that you were x-rayed only on the bottom teeth and not 
the top. 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 26, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180), and intraoral - complete series of radiographic images (D0210) provided on September 13, 
2022.