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

 
We decided that the Plan has to hold you harmless for the 2D and 3D photographic facial images (D0350 and 
D0351) provided on December 10, 2021. 
 
You asked the Plan to hold you harmless for the 2D and 3D photographic imaging. You say that you would like 
reconsideration because you did not request the imaging services and were not given the opportunity to deny 
treatment. The Plan denied your request. The Plan says that these are not covered benefits under your plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the 2D and 3D photographic imaging by a contract provider. The file does not show that 
the Plan provided notice that the 2D and 3D photographic imaging would not be covered. Under Medicare 
rules, this means the 2D and 3D photographic imaging is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the 2D and 3D photographic facial images (D0350 and 
D0351) provided on December 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0270 and D0272) provided on 
December 21, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you would like reconsideration because you 
were not told that you could only get 1 bitewing x-ray. The Plan denied your request. The Plan says this service 
is allowed one time every twelve months. 
 
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 bitewing x-rays are 
covered once per 12 months. The record shows that the Plan processed and paid for bitewing x-rays on the 
same date of service. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0270 and D0272) provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Freestyle Libre continuous glucose monitor
(CGM) supplies.
You asked the Plan to provide coverage for this equipment. You say that Freestyle Libre continuous glucose
monitor (CGM) supplies are medically necessary. The Plan denied your request. The Plan says Medicare
coverage criteria are not met. Maximus overturned the Plans denial for insufficient information in the case file.
The Plan requested a reopen and provided additional information. The Plan provided confirmation that you are
not treated with insulin.
The Plan is correct in this case. 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. Based on the medical records provided, do not meet these criteria. Medicare
rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to
provide coverage for Freestyle Libre continuous glucose monitor (CGM) supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 3. 
 
You asked the Plan to pre-approve core build up for tooth # 3. You say that you need this service. The Plan 
denied your request. The Plan says core build up for tooth # 3 is not medically necessary. 
 
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 covers core build up 
for tooth # 3 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 core build up for tooth # 3. Our 
reviewer says that core build up for tooth # 3 is not medically necessary. Our physician reviewer found the 
provided documentation does not support the need for the requested service. The documentation indicates that 
a crown is present on tooth # 3. The reviewer found that there was no narrative indicating why the present 
crown was to be replaced and a core buildup required. Therefore, the reviewer found that the requested core 
build up for tooth # 3 is not medically reasonable or necessary. 
 
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 core build up for tooth # 3 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core build up (D2950) for teeth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for teeth #30 and #10 to be provided 
by a contracted provider. 
 
You asked the Plan to pre-approve a crown. You say that the medical criteria for D2740 have been met. The 
Plan denied your request. The Plan says there is no clinical evidence to support medical necessity. 
 
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 covers a crown 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 a crown. Our reviewer says that D2740 
for teeth #30 and #10 are not medically necessary. Our physician reviewer found there is insufficient damage to 
the tooth to require the use of a crown restoration and it would not be considered necessary. 
 
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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for teeth #30 and #10 to be provided by a contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #18. 
 
You asked the Plan to pre-approve the crown. You say that these services are necessary. The Plan denied your 
request. The Plan says this crown is not medically necessary as there is excessive bone loss around the root of 
this tooth, and therefore there is a poor prognosis for this treatment. 
 
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 covers the crown 
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 the crown. Our reviewer says that the 
documentation does not meet the criteria for coverage of a crown restoration on tooth #18. 
Our physician reviewer found the documentation indicates that the bone support around tooth #18 is poor, and 
therefore there is a poor prognosis for long term retention of this tooth. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown (D2740) for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Detect provided on September 13, 2021.
You asked the Plan to pay for the CxBladder Detect. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.
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 pay for the CxBladder Detect. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case.
Our physician reviewer found CxBladder is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 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 CxBladder Detect have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 surgical extractions (D7210), and 2 removal of 
residual tooth roots (D7250). 
 
You asked the Plan to pre-approve the dental services. You say that your plan covers 3 extractions per year. 
You also say that you need 7 teeth to be extracted before you can be fitted for dentures. The Plan denied your 
request. The Plan says the requested services denied correctly. 
 
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 3 extractions are covered per 
calendar year, the frequency limit has been reached. The record shows that the Plan paid for 3 extractions that 
you received on February 25, 2022. Therefore, we decided that the Plan does not have to pre-approve 2 surgical 
extractions (D7210), and 2 removal of residual tooth roots (D7250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second pair of eyeglasses and the sales taxes/shipping 
fees purchased on October 26, 2021. 
 
You asked the Plan to pay for the vision services. You say that You should be reimbursed for these services up 
to the full allowance limit. The Plan denied your request. The Plan says they have agreed to pay for one of the 
pairs of eyeglasses; however, the second pair exceeds the limitations of your benefit and sales tax and shipping 
costs are not a covered benefit. 
 
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 one pair of eyeglasses (lenses and frames) every year with a $150 maximum 
allowance. 
 
We looked at the file and the Plan's rules. The documentation shows that the Plan has covered one pair of 
glasses for you in 2021. In addition, sales tax and shipping insurance/fees are not among those items/services 
listed as covered under this benefit. Based on this information, we decided that the Plan's rules for coverage of 
the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the second 
pair of eyeglasses and the sales taxes/shipping fees purchased on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 implant supported crowns (D6065). 
 
You asked the Plan to pre-approve implant supported crowns. You say that these services are necessary. The 
Plan denied your request. The Plan says these services 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 pre-approve 24 
implant supported crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and 
comprehensive oral evaluation (D0150) provided on January 3, 2022. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue and comprehensive oral evaluation. You say 
that the biopsy service should have applied to your medical benefits. The Plan denied your request. The Plan 
says the incisional biopsy of oral tissue is not a covered expense under your dental plan. The Plan also says that 
your benefits for the comprehensive oral evaluation have been satisfied and the frequency limitation 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, incisional biopsy of oral tissue 
(D7286) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 17, 2021 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the incisional 
biopsy of oral tissue (D7286) and comprehensive oral evaluation (D0150) provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you lost your dentures and would like 
them to be replaced. The Plan denied your request. The Plan says these services exceed the maximum counts 
allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
November 20, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve complete dentures. You say that these services are necessary. The Plan 
denied your request. The Plan says dentures (prosthodontics) are not covered by your benefit plan. 
 
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 a 
complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 7, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 7, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 7, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of May 7, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond May 7, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 7, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 7, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), deep 
sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says removal of torus mandibularis and therapeutic parenteral drugs 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of torus 
mandibularis and therapeutic parenteral drugs are not among those covered under this benefit. The general 
anesthesia is not requested for a covered procedure, and therefore is not medically necessary in this case. 
Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), deep 
sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at the time of implant placement (D6104) and 
an osseous, osteoperiosteal or cartilage graft (D7950). 
 
You asked the Plan to pre-approve dental graft services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services 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 pre-approve bone 
graft at the time of implant placement (D6104) and an osseous, osteoperiosteal or cartilage graft (D7950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and 
extraction (D7210) with an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation, and extraction with an oral surgeon. You 
say that the requested services are medically necessary. The Plan denied your request. The Plan says the 
services at issue are not covered unless they are performed by a participating general dentist. Dental services 
performed by an oral surgeon are not covered. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, and extraction with an oral surgeon have not been met. 
Specifically, the services at issue are not covered unless they are performed by a participating general dentist. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), 
and extraction (D7210) with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four biologic materials (D4265 x4), four surgical 
placements of implant bodies: endosteal implants (D6010 x4), and four bone replacement grafts for ridge 
preservation (D7953 x4). 
 
You asked the Plan to pre-approve the biologic materials, endosteal implants, and bone replacement grafts. The 
Plan denied your request. The Plan says these services are not covered under your benefit plan. 
 
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 four 
biologic materials (D4265 x4), four surgical placements of implant bodies: endosteal implants (D6010 x4), and 
four bone replacement grafts for ridge preservation (D7953 x4).