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

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and a semi-precision 
placement (D6191) provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and a semi-precision placement. You say that 
these services are medically necessary. The Plan denied your request. The Plan says the requested dental work 
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 
prefabricated abutment (D6056) and a semi-precision placement (D6191) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and bone 
replacement graft for ridge preservation - per site (D7953) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you assumed this provider was part of the Plan's 
dental 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 the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210) and bone replacement graft for ridge preservation - per 
site (D7953) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images and 
house/extended care facility call provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why this bill cannot be 
paid. The Plan denied your request. The Plan says these services are not covered by the Plan's 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 
intraoral complete series of radiographic images and house/extended care facility call provided on March 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940) provided on May 5, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the protective 
restoration (D2940) provided on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation (E2300), an expandable controller 
(E2377), a harness upgrade (E2313), an electronic connection between wheelchair controller and two or more 
power seating system motors E2311) and transfer handles (K0108). 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee has a pressure injury on 
her sacrum and requires the power tilt and power recline in order to relieve the pressure off of her seated area. 
The Plan denied your request. The Plan says the enrollee does not have significant problems with upper limb 
mobility which necessitate control of power options through the joystick, therefore, the expandable controller, 
harness and electronics are not medically needed. Needs can be meet with a group 3 PWC with single power 
option. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found provided records document that 
the enrollee has 5/5 bilateral upper extremity strength and is independent with grooming and eating thus 
indicating she has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches. Therefore (E2377, E2313, E2311) do not meet Medicare criteria for coverage. The 
requested power seat elevation feature is statutorily non-covered as it serves no primary medical purpose. The 
requested transfer handles do not serve a medical need and do not meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power seat elevation (E2300), an expandable controller (E2377), a harness 
upgrade (E2313), an electronic connection between wheelchair controller and two or more power seating 
system motors E2311) and transfer handles (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 27, 2022. 
 
You asked the Plan to pay for a consultation. You say that you were unaware you exceeded your maximum 
benefit. The Plan denied your request. The Plan says your annual dental benefit has already been met. 
 
The record shows your annual dental benefit has been exhausted. You have been asked to pay $121.80 for a 
consultation. This item/service falls within the dental services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 for a consultation (D9310) provided on July 27, 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 July 20, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you were unaware there was a frequency limit for 
this procedure. 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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), a 
panoramic x-ray (D0330) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office did not tell you that they did 
not take your insurance. 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 periodic oral evaluation (D0120), prophylaxis (D1110), a panoramic x-ray (D0330) provided on 
August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 19, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface covering system. 
 
You asked the Plan to pre-approve a flexible protective outer surface covering system. You say that this is 
necessary for the enrollee's prosthetic equipment. The Plan denied your request. The Plan says there is no need 
for the extra cover protection requested. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are 
specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has 
special needs for protection against unusually harsh environmental situations where it is necessary to protect 
the lower limb prosthesis beyond the level of protection usually required. 
 
We looked at the file and Medicare rules. In this case, there is no evidence that there is an unusually harsh 
environmental situation for the enrollee. Based on this information, we decided that Medicare rules for coverage of a flexible protective outer surface covering system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a flexible protective outer surface covering system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266), the implants 
(D6010), bone grafts (D6104), and an appliance removal (D7997) for tooth #6, #7, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that there are no in-network providers who can 
provide the dental services that you need. The Plan denied your request. The Plan says dental services from an 
out-of-network provider are not covered by your supplemental benefits. Also, there were multiple in-network 
provider given to the enrollee that they can use for the dental services that were requested. 
 
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 are requesting 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 pre-approve the guided 
tissue regeneration (D4266), the implants (D6010), bone grafts (D6104), and an appliance removal (D7997) for 
tooth #6, #7, and #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the lower right 
and upper left quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that you need a deep cleaning. The Plan denied 
your request. The Plan says that there must be at least four teeth in the same part of the mouth that needs 
treatment. 
 
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 periodontal 
scaling when the services are medically necessary and reasonable.  
 
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 periodontal scaling. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that a review of the documentation 
indicates that the upper left and lower right quadrants appear to have three teeth present in each quadrant. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in the lower right and upper left quadrants 
(D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to expandable controller (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial due to 
being at risk for developing pressure sores. You need the seat elevator to assist you with standing up and assist 
you with putting on your clothes. The stroke makes it harder for you to move around without assistance in 
getting in and out of the recliner. You have no assistance with mobility. The Plan denied your request. The Plan 
says the seat elevator is never covered by Medicare because it is for your convenience. The expanded controller 
components are requested to control power options through the joystick. There is not a medical need to control 
power options through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness for 
upgrade to expandable controller (E2313) and an expandable controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on June 
3, 2022. 
 
You asked the Plan to pay for the dental services. You say that your teeth needed to be removed for radiation 
treatment. The Plan denied your request. The Plan says this service 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 the 
problem focused limited oral evaluation provided on June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you knew it was not time for 
you to be seen for this exam until December 3, 2023. You also say that you had to be seen due to damages the 
dental provider did on your mouth. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 2, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection between the controller and 
two or more power options (E2311). 
 
You asked the Plan to pre-approve the electronic connection. You say that this connection is medically 
necessary for the enrollee's operation of the power wheelchair. The Plan denied your request. The Plan says the 
criteria for coverage have not been satisfied. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connection is necessary when it is 
medically necessary for the enrollee to control two or more of the motors from a single interface.  
 
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 electronic connection. Our reviewer says that the requested electronic connection between the controller and two or more power options is not 
medically reasonable and necessary. Our physician reviewer found that based on the medical records provided 
there is no documentation that the electronic connection (E2311) to control the tilt and elevating leg rests on 
the power wheelchair through a joystick at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the patient. Provided records document that the enrollee has upper extremity 
pinch and grip strength reported as within functional limits and that she is independent with feeding thus 
indicating she has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches.  
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection between the controller and two or more power 
options (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on August 25, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $18 
copayment coinsurance for each specialist's office visit and a $203 deductible] for an office visit.  
 
You have been asked to pay $18 copayment coinsurance for each specialist's office visit and a $203 deductible] 
for an office visit. This item/service falls within the Physician/Practitioner services, including doctor's office 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. 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 waive the copayment for an office visit on August 25, 
2022.