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

 
We decided that the Plan has to pay for the Wound care set (A6550) provided on March 8, 2022. 
 
You asked the Plan to pay for procedure code A6550. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case for use of the KX modifier for code A6550. Therefore, we decided 
that the Plan has to pay for the Wound care set (A6550) provided on March 8, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and 
bitewing x-rays (D0274) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that these services are not covered when received by an out-of-
network provider. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage (EOC) or Dental 
Rider. Without the correct EOC or Dental Rider we are unable to determine if the claim was processed 
correctly. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150), 
prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 4, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services on June 10, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were advised you would be 
reimbursed at 45% of the providers charge. 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 the dental services on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on June 6, 2022. 
 
You asked the Plan to pay for fluoride varnish. You say that this service should be covered. The Plan denied 
your request. The Plan says the topical application of fluoride varnish (D1206) is not covered by 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 the 
topical application of fluoride varnish (D1206) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture (D5810) provided on May 18, 
2022. 
 
You asked the Plan to pay for the dental item. You say that you were advised by a plan representative what 
services would be covered. You also say that you were not advised this service would not be covered. The Plan 
denied your request. The Plan says the interim partial denture is not a covered dental item. 
 
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 interim partial denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim partial denture (D5810) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement on tooth #2 (D3221), vertical bitewing x-
ray (D0277), prophylaxis (D1110), and a periodic oral evaluation (D0120) provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. 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 pulpal debridement on tooth #2 (D3221), vertical bitewing x-ray (D0277), prophylaxis (D1110), and 
a periodic oral evaluation (D0120) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown repair (D2980) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that the crown repair was necessary. You say that the 
crown had broken off with a sharp edge that was cutting your mouth. The Plan denied your request. The Plan 
says crown repair is not a covered 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 crown repair is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown repair 
(D2980) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement crown (D2920) tooth #19 provided on July 20, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the cement fell off 9 months after you had the 
procedure, so you should not be responsible for the bill. 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. Recement or re-bond inlay, 
onlay, partial restoration, crown is limited to 1 per tooth/24 months. 
 
  We looked at the file, the Plans rules, and Medicares rules. The record shows your benefit for the requested 
recement crown (D2920) tooth #19 was exhausted on date of service November 29, 2021. Therefore, we 
decided that the Plan does not have to pay for recement crown (D2920) tooth #19 provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
network. 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 dental services provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation on May 17, 2022. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a core build-up (D2950), 
and an office visit for observation (D9430), provided by a participating provider on June 2, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, a core build-up, and an office visit for observation. You 
say that your temporary crown fell out, and you needed to go get the nerve covered up again. The Plan denied 
your request. The Plan says the rendered dental services 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 a limited 
oral evaluation (D0140), a core build-up (D2950), and an office visit for observation (D9430), provided by a 
participating provider on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided from April 11, 2022 to July 13, 
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 dental services provided from April 11, 2022 to July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) and consultation (D9310) 
provided on March 3, 2022. 
 
You asked the Plan to pay for dental services. You say that you were referred to a provider for a procedure, 
during the consultation it was determined you needed a different procedure they could not perform. The Plan 
denied your request. The Plan says this service is not covered under your 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 pulp vitality tests 
(D0460) and consultation (D9310) are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for pulp vitality tests (D0460) and consultation (D9310) provided on March 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 1, 2022, to June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration. 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 dental services provided on June 1, 2022, to June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0220) provided by an out-of-network provider on May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the in-network providers available to you were 
mostly 
pediatric providers or out-of-town providers. 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 limited oral evaluation (D0140) and intraoral imaging (D0220) provided by an out-of-network 
provider on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services received from February 7, 2022, to May 
5, 2022. 
 
You asked the Plan to pay for the services. You say that you did not know the doctor was not in-network. The 
Plan denied your request. The Plan says services must be provided in-network in order to be eligible for 
payment. 
 
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 anesthesia services received from February 7, 
2022, to May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32666 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 32666. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 32666 is bundled into payment for code 32669. 
 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 32666 
is a column II code to column I code 32669. 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 32666 billed for date of service June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that medical 
records are provided to support medical necessity. The Plan denied your request. The Plan says the enrollee 
does not have truncal edema, has not completed a four-week trial of a non-segmental or s segmental model 
without calibrated gradient pressure and has not had a trial of this PCD including pre and post measurements of 
her legs. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on December 24, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says that the member 
was enrolled in hospice. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for laboratory services provided on December 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you have neuropathy and cannot perform 
finger-prick testing. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) you 
received on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were a new patient at this office, so this 
service should be 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. Under the Plan rules, 
comprehensive oral exams are only covered once every three years, regardless of the reason. 
 
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 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) 
you received on June 13, 2022.