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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you are appealing the denied CGM. 
The Plan denied your request. The Plan says the Medicare criteria was 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth #'s 4, 5 and 15 (D7210), and alveoloplasty in conjunction with extractions (7311) to 
be provided by an OON provider. 
 
You asked the Plan to pre-approve codes D7210 and D7311. You say that you do not agree with the denial and 
are asking for a reconsideration. The Plan denied your request. The Plan says you may contact us for a dentist 
that is in-network in your area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth #'s 4, 5 and 15 (D7210), and 
alveoloplasty in conjunction with extractions (7311) to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. You say that you need this implant to chew easily. The Plan 
denied your request. The Plan says the requested 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 pre-approve 
dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for progressive lens (V2781), oversize lens (V2780), and 
anti-reflective coating provided on October 28, 2022. 
 
You asked the Plan to pay more for progressive lens (V2781), oversize lens (V2780), and anti-reflective 
coating. You say that last year when you got your glasses, you were reimbursed for $547.40. You also say you 
do not understand why you are paying so much more this time. The Plan denied your request. The Plan says 
they have paid the maximum amount covered by the Plan for this service. 
 
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 Plan covers up to $250 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $250 every year for non-
Medicare covered prescription eyewear. The Plan rules also say you are responsible for any amount above the 
eyewear coverage limit. The Plan rules also say if you choose a provider outside of the network, you may be 
responsible for additional costs. Based on this information, we decided that the Plan's rules for coverage of 
progressive lens (V2781), oversize lens (V2780), and anti-reflective coating have not been met. Therefore, we 
decided that the Plan does not have to pay more for progressive lens (V2781), oversize lens (V2780), and anti-
reflective coating provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper implanted removable denture (D6110). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item 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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper 
implanted removable denture (D6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on October 19, 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 February 26, 2019. 
Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and bathtub wall rail. 
 
You asked the Plan to pre-approve a shower chair and bathtub wall rail. You say that you cannot walk, and you 
need these this durable medical equipment. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and bathtub wall rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944). 
 
You asked the Plan to pay for an occlusal guard. You say that you need this t alleviate muscle tension. The Plan 
denied your request. The Plan says mouth guards 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 an 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft. You say that you would like the Plan to approve 
this dental work. The Plan denied your request. The Plan says the requested dental 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 pre-approve a 
bone replacement graft for ridge preservation (D7953).
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 the CGM. You say that it is medically necessary that the enrollee receives 
the CGM. The Plan denied your request. The Plan says the Medicare criteria was 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM 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 complete dentures (D5110) provided on September 1, 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 July 17, 2018. Therefore, 
we decided that the Plan does not have to pay for complete dentures (D5110) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI. 
 
You asked the Plan to pre-approve SSBCI. You say that you received the benefit last year and should qualify. 
The Plan denied your request. The Plan says there is no documentation that the member meets criteria. The 
Plan also says that multiple attempts were made to obtain medical records, but additional supporting 
documentation was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. The record 
shows the Plan requested medical records, but did not receive any. We cannot verify you meet the criteria 
without the missing medical records. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefit for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the requested CGM is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Freestyle Libre 3 is not specified as a product 
that may be billed using code E2103. 
 
  We looked at the file and Medicare rules. The records show that you are requesting coverage of a non-
adjunctive CGM. As of January 1, 2023, the appropriate coding for a non-adjunctive CGM is E2103. The 
Freestyle Libre 3 is not specified as a product that may be billed using code E2103. Therefore, the Freestyle 
Libre 3 is not eligible for reimbursement. Based on this information, we decided that Medicare rules for 
coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis Sensor. 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that the enrollee needs this 
CGM. The Plan denied your request. The Plan says the enrollee is not using insulin. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 Mis Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 8) provided on May 11, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 extractions, of an erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210 x 8) provided on May 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Phesgo. 
 
You asked the Plan to pre-approve Phesgo. You say that the requested Phesgo is medically necessary. The Plan 
denied your request. The Plan says that the requested Phesgo is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Phesgo. Our reviewer says that the 
requested Phesgo is medically necessary. Our physician reviewer found the requested use of Phesgo is FDA-
approved for the enrollees diagnosis. The enrollee received docetaxel with initial treatment with pertuzumab 
and trastuzumab. She is on maintenance therapy since 2016 changed to Phesgo around October 2021 and stable 
disease. Per the NCCN Guidelines Pertuzumab, trastuzumab, and hyaluronidase-zzxf injection for 
subcutaneous use may be substituted anywhere that the combination of intravenous pertuzumab and 
intravenous trastuzumab are given as part of systemic therapy. The documentation supports that the requested 
drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Phesgo have been met. Therefore, we decided that the Plan has to pre-approve 
Phesgo.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health service provided on October 05, 
2022. 
 
You asked the Plan to pay for an outpatient mental health service. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient mental 
health service provided on October 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99213) provided on September 07, 
2022. 
 
You asked the Plan to pay for a specialist office visit (99213). You say that you have attached medical records 
to show services rendered were medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a specialist office visit 
(99213) provided on September 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an amalgam and intraoral x-ray (D2160, D0220) 
provided on August 18, 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. Coverage for the intra-oral x-ray denied correctly as you have exceeded the plans benefit limit of 
once per year. 
 
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. 
Coverage for the intra-oral x-ray denied correctly as the record indicates you received these services on May 
25, 2022, which is within the plans benefit limitation of one procedure code per plan year. Therefore, we 
decided that the Plan does not have to pay more for an amalgam and intraoral x-ray (D2160, D0220) provided 
on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal guard (D9945) provided on September 22, 2022. 
 
You asked the Plan to pay for occlusal guard (D9945). You say that the need for an occlusal guard came 
unexpectedly following the placement of a bridge which caused a change sufficient to prevent your ability to 
wear a retainer required to prevent future misalignments. The Plan denied your request. The Plan says this is 
not covered under any normal circumstances. 
 
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 occlusal 
guard (D9945) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneer (D2962) for teeth #23, #24, #25, and #26. 
 
You asked the Plan to pre-approve labial veneer. You say that you are having trouble biting without pain. The 
Plan denied your request. The Plan says the requested 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 pre-approve 
labial veneer (D2962) for teeth #23, #24, #25, and #26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has plantar fasciitis. 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 does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.