Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wellness visit provided on September 03, 2022, to September 
07, 2022. 
 
You asked the Plan to pay for wellness visit. You say that you are requesting reconsideration. 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 wellness visit provided 
on September 03, 2022, to September 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and an abutment support to 
a crown (D6059) for tooth #8. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to have the implant 
overturned. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the custom abutment and an abutment support to a crown are not covered by the 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 pre-approve a 
custom abutment (D6057) and an abutment support to a crown (D6059) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011) for tooth #19. 
 
You asked the Plan to pre-approve the dental services. You say that the surgical access to an implant body 
(second stage implant surgery) (D6011) for tooth #19 is medically necessary. The Plan denied your request. 
The Plan says dental code D6011 is not listed, and therefore 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 
surgical access to an implant body (second stage implant surgery) (D6011) for tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns on tooth #8 and 9 (D2750). 
 
You asked the Plan to pre-approve the crowns. You say that you disagree with the denial of the crowns. The 
Plan denied your request. The Plan says the records that were received from the provider did not clearly show 
why the requested services are needed. 
 
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 the crowns have been met. The Plan 
has made multiple attempts to obtain documentation to show why the treatment being requested is medically 
necessary. Therefore, we decided that the Plan does not have to pre-approve crowns on tooth #8 and 9 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system. 
 
You asked the Plan to pre-approve a CGM system. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
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 CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ozempic (J3490). 
 
You asked the Plan to pre-approve the Ozempic. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Ozempic (J3490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740), core buildup (D2950), and 
endodontic therapy (D3320) for tooth #13 provided by an out-of-network provider on August 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee thought the provider was an 
in-network provider because they said they took their insurance. 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. 
 
  The enrollee has been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation when the enrollee agreed to pay when they enrolled in 
the Plan. Therefore, we decided that the Plan does not have to pay more for a crown (D2740), core buildup 
(D2950), and endodontic therapy (D3320) for tooth #13 provided by an out-of-network provider on August 29, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you should 
not have to pay this copayment, this is a screening service. 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 a $350 
copayment for outpatient hospital services.  
 
You have been asked to pay the allowed amount of $51.27 which is less than the $350 copayment for a 
computed tomography (CT) scan. This item/service falls within the outpatient hospital 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 waive the copayment for a computed tomography (CT) scan provided on 
August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's physician ordered services as it was 
deemed medically necessary for their care. The Plan denied your request. The Plan says a prior authorization 
was not obtained, and services rendered are deemed not medically necessary. 
 
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 genetic testing provided on May 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of x-rays provided on October 
6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing 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 March 27, 2019. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of x-rays provided on 
October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluoride carriers. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee would benefit from the requested 
service due to radiation therapy. 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. Fluoride carriers are not 
covered under the Plans dental benefits. 
 
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 
fluoride carriers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment on tooth #31 (D6057) and an 
abutment supported crown on tooth #31 (D6058). 
 
You asked the Plan to pre-approve an abutment and crown. You say that you disagree with the denial of the 
requested dental services. The Plan denied your request. The Plan says a custom abutment (D6057) and an 
abutment supported crown (D6058) are 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 pre-approve a 
custom abutment on tooth #31 (D6057) and an abutment supported crown on tooth #31 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthodontic retention (removal of appliances, 
construction, and placement of retainers) (D8680). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee's 
braces to be removed. You say the brackets are cutting the enrollee's mouth and after a thorough discussion 
with your dentist, it was decided the braces should be removed. The Plan denied your request. The Plan says 
orthodontic retention (D8680) is not covered by the Plan's enhanced supplemental 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 pre-approve 
orthodontic retention (removal of appliances, construction, and placement of retainers) (D8680).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0675-RR, E0673-NU-RT, 
and E0673-NU-LT) provided on July 20, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment (E0675-RR, E0673-NU-RT, and E0673-NU-LT) provided on 
July 20, 2022.
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 shoe inserts are medically necessary. 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.   
 
The record shows that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee's care can be 
provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until ready for discharge or transfer to a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the guidelines are strict and the CGM would make it 
easier for you. The Plan denied your request. The Plan says the Medicare criteria for the CGM were 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 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 therapeutic continuous 
glucose monitor (CGM).
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 you disagree with the denial of shoe inserts. 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.   
 
The record shows that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you have tremors which makes it 
difficult to check your blood sugar levels. The Plan denied your request. The Plan says that the coverage 
criteria has not been 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 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 therapeutic 
CGM and supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on September 10, 
2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the 
copayment. 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. This item/service falls within the emergency 
care 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 emergency care provided on 
September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2025) and lenses (V2781) provided on June 9, 
2022. 
 You asked the Plan to pay for frames (V2025) and lenses (V2781). You say that you had a second eye 
examination this year because you had a stroke that affected her vision and needed one. The Plan denied your 
request. The Plan says the health plan has determined that the vision plan vendor received your reimbursement 
request for frames and lenses purchased on 06/21/2022 and they have already issued a reimbursement check to 
you of $90. The Plan also says therefore, they are unable to approve your request for additional payment. 
 
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 these services when the Plan reimburses up to $90 per calendar year for glasses. 
 
We looked at the file and the Plan's rules. The Plan rules say if you use a non-participating provider, you will 
need to pay out-of-pocket and submit for reimbursement. The Plan also says you would be reimbursed up to 
$90 per calendar year. The record shows this benefit was already exhausted with date of service June 21, 2022. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2025) and lenses (V2781) 
have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2025) and lenses 
(V2781) provided on June 9, 2022.