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

 
We decided that the Plan does not have to pay for the endosteal implant (code D6040) you received on October 
21, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that your Plan navigator assured you that this 
would be covered.  You said that you have a limited income and would not have had the procedure if it was not 
covered. The Plan denied your request. The Plan says endosteal implants are not covered under your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your Evidence of Coverage 
lists every single dental code that is covered under your dental benefit.  Code D6010 (endosteal implant) is not 
listed in the listing of covered dental services. 
 
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 
endosteal implant (code D6040) you received on October 21, 2021.   
Your complaint about the Plan navigator verbally giving you incorrect information is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments, twice 
monthly for one year. 
 
You asked the Plan to pre-approve the requested dosing of IVIG. You say that this is necessary as other 
treatment options would not help quickly enough to alleviate the enrollee's symptoms. The Plan denied your 
request. The Plan says a three-month approval was issued, but further treatments beyond this are not indicated 
at this time. 
 
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 requested dosing of IVIG. Our 
reviewer says that the requested treatment plan with IVIG is not considered medically reasonable and 
necessary. Our physician reviewer found the proposed use of the drug is not readily supported within the 
Compendia. There is otherwise no indication from the records provided that the member's condition is 
otherwise refractory to other standard therapies that can be utilized at this time. In as much it cannot be 
determined that the proposed service would be reasonable and necessary. 
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 requested dosing of IVIG have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments, twice monthly for one year.
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 disagree with the denial. 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 perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 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 pre-approve the dentures (D5110). 
 
You asked the Plan to pre-approve the dentures. You say that the service should be covered. The Plan denied 
your request. The Plan says the maximum frequency for this service has 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, 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 the 
dentures (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on April 28, 2021 and May 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like reconsideration because your 
dentist believed they accepted your insurance. The Plan denied your request. The Plan says out-of-network 
dental services are 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 Plan's coverage rules apply in this case. The Plan does not cover out-
of-network dental services. 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the record indicates that these services were 
rendered out-of-network. The Plan does not cover preventive dental services when rendered out-of-network. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on April 28, 2021 and 
May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that your dentures broke, and you need 
new ones because you are becoming malnourished. The Plan denied your request. The Plan says the requested 
service will exceed the Plan's frequency limit. 
 
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 Plan covers a complete 
upper denture once every 5 years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that an upper denture was 
previously covered on October 6, 2020. Based on this information, we decided that the Plan's frequency limit 
for coverage of a complete upper denture would be exceeded with the requested service. Therefore, we decided 
that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 30, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam (code D0150) you received 
on November 5, 2021. 
 
You asked the Plan to pay for the comprehensive dental exam. You say that you went to one dentist in October 
and were told over the phone that they would be able to handle all of your dental care in-house.  However, then 
you had to go to another office for oral surgery.  You said that the oral surgeon had to do another exam.  You 
do not think you should have to pay for this. The Plan denied your request. The Plan says comprehensive dental 
exams are only covered once every three years. You already received a covered comprehensive dental exam on 
October 21, 2021, so you have exhausted this 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. In this case, your plan only 
covers one comprehensive dental exam every three years, regardless of the reason.  
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 
comprehensive dental exam (code D0150) you received on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331) for tooth # 2. 
 
You asked the Plan to pre-approve the dental service. You say that you have complete coverage. You say that 
you need coverage for this service. You also say that you are in pain and need assistance. The Plan denied your 
request. The Plan says treatment of root canal obstruction is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested treatment of root canal 
obstruction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve treatment of root canal obstruction (D3331) for tooth # 2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the maximum allowed frequency for this service has 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, the requested items or services are not 
among those covered under this benefit. Specifically, records indicate the member received two crowns on 
January 3, 2022. This means the maximum allowed frequency for this service has been exhausted and is not 
covered. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high 
noble metal (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are having problems with the dentures 
that you received previously. You say that they do not fit correctly. You also say that you do not have money to 
pay for new dentures. The Plan denied your request. The Plan says dentures are covered once every 5 plan 
years. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the 
frequency limit of once every 5 plan years has been exceeded. The record shows that the Plan paid for 
complete dentures that you received on May 17, 2021. Therefore, we decided that the Plan does not have to 
pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right facet joint 
nerves. 
 
You asked the Plan to pre-approve the right-sided RFA procedure. You say that you believe that this should be 
covered because you had this same procedure on the left side, and it eliminated your pain. The Plan denied 
your request. The Plan says you have not had two MBBs on the right side with 80% or more pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joints is covered when dual 
MBBs are provided producing at least 80% pain relief.  
 
In this case, the records show you had a single MBB on the right side. This did not produce 80% pain relief. As 
such, the criteria for coverage of the requested RFA procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right facet joint nerves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two removals of lateral exostosis (D7471 x2). 
 
You asked the Plan to pre-approve the removals of lateral exostosis. You say that you need this surgery 
because your tooth is cutting you in multiple places. The Plan denied your request. The Plan says this service is 
not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
removals of lateral exostosis (D7471 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on September 
24, 2021. 
 
You asked the Plan to pay for the crown. You say that you did not know that this service would not be covered, 
and you would not be able to get reimbursement for this cost. The Plan denied your request. The Plan says 
crowns are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic crown (D2740) provided on September 24, 2021.
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 disagree with the denial. 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 perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 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 pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you purchased your current 
dentures four years ago and they no longer fit. You also say that you are missing most of your bottom teeth and 
it is hard for you to eat without the approval of this denture. The Plan denied your request. The Plan says this 
service is not covered under your benefit package. 
 
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 
complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail. 
 
You asked the Plan to pre-approve these services. You say that you need the rail to prevent falls while 
showering. The Plan denied your request. The Plan says the services are not 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 bathtub wall rail.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight wheelchair from an out-of-network 
provider. 
 
You asked the Plan to pre-approve these services. You say that you trust this provider and go to them for 
everything. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 ultralight wheelchair from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950) and crown (D2740). 
 
You asked the Plan to pre-approve a core buildup and crown. You say that the services are medically 
necessary. The Plan denied your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, these services are not listed in the Plan's benefit chart. 
This means the services are not covered. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup (D2950) and crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 4KScore test (81539) provided on July 26, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the 4kScore test. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says non-urgent services should be rendered by 
network providers. 
 
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 the 4KScore test 
(81539) provided on July 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV). 
 
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 not covered. 
 
  The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment (DME) 
is covered in cases of irreparable damage or when the item has exceeded the reasonable useful lifetime period. 
 
We looked at the file and Medicare rules. The file shows that the current POV is not irreparably damaged or 
more than five years old. 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 Group 2 power 
operated vehicle (POV).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure (basivertebral nerve ablation) is experimental for back pain. More research is needed. 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction of intraosseous basivertebral nerve for the enrollee.