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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this will make it 
easier to manage your diabetes. The Plan denied your request. The Plan says the requirements for coverage 
have 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 a Freestyle 
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2740 x3) provided on May 27, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the crowns. You say that the crowns you have gotten keep falling off. You 
also say that you told the dentist office that you want to cancel your loan because you do not want to go to them 
anymore. 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. This 
claim was processed correctly, and the amount you took the credit line out for is correct based on the services 
rendered. Therefore, we decided that the Plan does not have to pay more for the crowns (D2740 x3) provided 
on May 27, 2022, by an out-of-network (OON) provider.   
Your complaint about the poor quality of the crowns you received 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported interim fixed denture for 
an upper edentulous arch (D6118), surgical placement of an implant body: endosteal implants (D6010 x 3), 
semi-precision attachmentsplacement (D6192 x 2), and the semi-precision abutmentsplacement (D6191 x 3). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these dental items/services are 
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 requested items/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant/abutment supported interim fixed denture for an upper edentulous arch (D6118), surgical placement of 
an implant body: endosteal implants (D6010 x 3), semi-precision attachmentsplacement (D6192 x 2), and the 
semi-precision abutmentsplacement (D6191 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and two extractions provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve a consultation and extractions. You say that you have coverage for one 
extraction which should be covered. The Plan denied your request. The Plan says the requested items and 
services are not covered when received by an oral surgeon. 
 
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 when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a consultation and two extractions provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of residual tooth roots on tooth #23 
(D7250) provided on February 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the surgical removal of residual tooth roots (D7250) is 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 pay for the 
surgical removal of residual tooth roots on tooth #23 (D7250) provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
March 29, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the cost sharing was applied 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.  
 
We looked at the file, and Medicare rules. 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 20% coinsurance for periodontal scaling and root planning. 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 periodontal scaling and root planing (D4342) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213), mandibular partial denture 
- cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214), extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and 
endodontic therapy, molar tooth (excluding final restoration) (D3330). 
 
You asked the Plan to pre-approve an upper partial denture, lower partial denture, tooth extractions and root 
canal. You say that this is expensive dental work, and you would like your plan to cover part of the cost. The 
Plan denied your request. The Plan says these services are not covered under your 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 
maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5213), mandibular partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5214), extractions, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140), and endodontic therapy, molar tooth (excluding final restoration) 
(D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns on tooth #3 and 13 
(D6059). 
 
You asked the Plan to pre-approve crowns. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says abutment supported crowns (D6059) 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 
abutment supported crowns on tooth #3 and 13 (D6059).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on March 31, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.    
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation does not support that the procedure was distinct or independent from 
other services performed. Based on this information, we decided that Medicare rules for coverage of services 
billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the 
mass spectrometry and tandem mass spectrometry services coded 83789 provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), or pay 
more for the pontic (D6245), two retainer crowns (D6740 x2), two core buildups, including any pins when 
required (D2950 x2), and six resin-based composites (D2330 x3 and D2331 x3) provided from March 10, 
2022, to May 10, 2022.  
You asked the Plan to pay for the problem focused limited oral evaluation, and to pay more for the pontic, 
retainer crowns, core buildups, and resin-based composites. You say that you do not want to pay for these 
services. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a 
covered service. The Plan also says that these services processed correctly in accordance with your Evidence of Coverage. 
 
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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract also says that you are 
responsible for a 50% coinsurance for each pontic (D6245), retainer crown (D6740), core buildup, including 
any pins when required (D2950), and resin-based composites (D2330 and D2331) you receive after your $50 
deductible has been met. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140), or pay more for the pontic (D6245), two retainer crowns (D6740 x2), two core 
buildups, including any pins when required (D2950 x2), and six resin-based composites (D2330 x3 and D2331 
x3) provided from March 10, 2022, to May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a core buildup to be provided with an approved crown for tooth 
#30, and a crown with core buildup for tooth #29. 
 
You asked the Plan to pre-approve the requested dental services. You say that the dental services should be 
approved as requested. The Plan denied your request. The Plan says that it was found that a crown is necessary 
for tooth #30, but the core buildup was not. Neither the crown nor the core buildup was found to be necessary 
for tooth #29. 
 
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 the requested 
dental services 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 requested dental services. Our 
reviewer says that the requested crowns/core buildups are reasonable and necessary and meet the Plan's criteria. 
Our physician reviewer found a review of the documentation indicates that the defective crown on tooth #30 
(marginal caries) was removed and a root canal was performed. Due to the significant coronal breakdown a 
core buildup was necessary to provide stability and support for the crown. Tooth #29 exhibited recurrent caries 
and an unsupported buccal cusp associated with the three-surface restoration in the tooth. A core buildup and 
crown restoration is medically reasonable and necessary to provide adequate function and support. The 
documentation provided meets the criteria for coverage for a core buildup (D2950) for teeth #29 and 30, and a 
crown restoration (D2740) for tooth #29. 
 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 requested dental services have been met. Therefore, we decided that the 
Plan has to pre-approve a core buildup to be provided with an approved crown for tooth #30, and a crown with 
core buildup for tooth #29.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 50 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 50 additional PT visits. You say that the enrollee will benefit from 
continued physical therapy. The Plan denied your request. The Plan says the additional 50 visits do not meet 
criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 50 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy 
generally is not accepted as specific and effective therapy for the enrollees condition beyond what was 
approved by the Plan. The enrollee has had prior therapy and the documentation does not reveal that the 
enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment, that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollees current condition or to prevent or slow further deterioration. The enrollee has had instruction in a 
home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 50 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 50 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation - problem focused (D0140), 
panoramic radiographic image (D0330), and re-cement or re-bond crown (D2920) provided February 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like these services covered. 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation - problem focused 
(D0140), panoramic radiographic image (D0330), and re-cement or re-bond crown (D2920) provided February 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) and an extraction (D7140) 
provided by a participating provider on May 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have Alzheimer, and you could not 
understand how to hold her mouth for this to happen, so the office was not getting a clear picture of what was 
wrong with your tooth. The Plan denied your request. The Plan says your benefit for D0230 has already been 
exhausted. D7140 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, certain limitations apply. The record 
shows your benefit for D0230 was exhausted on date of service May 27,2022. This benefit does not include 
D7140. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0230) and an 
extraction (D7140) provided by a participating provider on May 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging scan 
provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that this billing is incorrect, and you should 
not have a copayment for this service. The Plan denied your request. The Plan says the copayment that was 
applied was correct. 
 
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 $165 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, Nuclear 
Scans and PET scans, per date of service.  
 
You have been asked to pay a $165 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies (Pa) 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 magnetic resonance imaging (MRI) scan 
provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crowns (D6752) for tooth #'s 22 and 27 and pontics 
(D6242) for tooth #'s 23, 24, 25, and 26. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you recommend a fixed partial 
denture due to wear, pulpal necrosis, and infection. The Plan denied your request. The Plan says that the 
prognosis is poor due to the length of the bridge with the condition of the remaining teeth, periodontal support, 
and lack of alignment with the path of insertion. 
 
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 the retainer 
crowns and pontics 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 retainer crowns and pontics. Our 
reviewer says that the documentation provided meets the criteria for coverage for a fixed bridge replacing tooth 
#'s 23, 24, 25, and 26 using tooth #'s 22 and 27 as abutment retainers. Our physician reviewer found the 
documentation indicates that tooth #'s 23, 24, 25, and 26 require extraction due to severe wear and pulpal 
infection. The bone support of the abutment tooth #'s 22 and 27 appears good. Our reviewer also found that a 
fixed bridge is medically reasonable. 
 
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 retainer crowns and pontics have been met. Therefore, we decided that the 
Plan has to pre-approve retainer crowns (D6752) for tooth #'s 22 and 27 and pontics (D6242) for tooth #'s 23, 
24, 25, and 26.  
 
 
 
 
 
 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.