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

 
We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a breast prosthesis. You say that supporting documents have been submitted 
to confirm medical necessity. The Plan denied your request. The Plan says a mastectomy sleeve is denied as 
non-covered since it does not meet the definition of a prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is denied as noncovered, 
since it does not meet the definition of a prosthesis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breast prosthesis have not been met. The requested sleeve is not a covered item. Therefore, we 
decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the provider has opted out of Medicare and is not eligible for 
payment. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120) and prophylaxis (D1110) provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care have not been met. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider advised you that they were in-
network. You also say that you were told you would not have to pay anything out of pocket. 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 Plan's 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 14, 2022, with the 
payment of intraoral complete series x-ray (D0210). Therefore, we decided that the Plan does not have to pay 
for a panoramic radiographic image (D0330) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), 
prophylaxis (D1110), fluoride application (D1208), and crown (D2751) provided on February 22, 2022, by the 
non-assigned dentist. 
 
You asked the Plan to reimburse you for the dental services. You say that you were in a great deal of pain. You 
say that you could not get an appointment soon with an in-network dentist. You say that in this pandemic era, 
out of network dentists are getting paid by all dental insurance. You also say that the services were medically 
necessary. The Plan denied your request. The Plan says routine dental services provided by the non-Plan 
provider are not covered because they were not authorized and not urgently needed. 
 
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 dental services performed by the 
non-assigned dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), prophylaxis (D1110), fluoride 
application (D1208), and crown (D2751) provided on February 22, 2022, by the non-assigned dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392), 
limited oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) 
provided March 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you are disabled and have been using this 
dentist for years. 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. Additionally, the limited oral exam and periapical 
x-rays are not covered under your benefits under any circumstance. Therefore, we decided that the Plan does 
not have to pay for the resin-based composite - two surfaces, posterior (D2392), limited oral evaluation - 
problem focused (D0140), and intraoral - periapical first radiographic image (D0220) provided March 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation - problem focused (D0140) 
and intraoral - periapical first radiographic image (D0220) provided on May 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told your plan covers up to 
$2,000 of dental treatment. 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 a limited oral evaluation - problem focused 
(D0140) and intraoral - periapical first radiographic image (D0220) provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96374) provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 96374 is not supported in the medical record. Specifically, code 96374 is 
assigned a PC/TC indicator of 5. This means that payment may not be made for these services when they are 
provided to hospital inpatients or patients in a hospital outpatient department. As place of service (POS) 23 was 
billed on this claim, these services are not payable. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (96374) provided on January 24, 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), 
bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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), bitewing x-rays (D0274), and periapical x-
rays (D0220, D0230) provided on June 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeomin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Xeomin is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has spasticity of the lower 
limb. This is not a medically-accepted indication for the use of Xeomin. The records and Medicare-approved 
drug compendia do not support the use of Xeomin. The services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xeomin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were initially quoted $909 for the services. 
You say that you received a bill six months later for another $823. You also say that you are on a restricted 
income. The Plan denied your request. The Plan says crown and core build up are not listed as covered dental 
services. 
 
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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical access to an implant body (D6011), a bone 
replacement graft for ridge preservation, per site (D7953) and drugs or medicaments dispensed in the office for 
home use (D9630). 
 
You asked the Plan to pre-approve dental services. You say that you are in pain and in dire need of these dental 
services. The Plan denied your request. The Plan says the requested dental services are not listed as a covered 
benefit with 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. 
 
 
 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 
surgical access to an implant body (D6011), a bone replacement graft for ridge preservation, per site (D7953) 
and drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete dentures (D5110) provided on April 26, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the provider was out-of-
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 maxillary complete dentures (D5110) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an evaluation (D0150), an intraoral (D0220), bitewings 
(D0274), fillings (D2392) (D2393), and pulp caps (D3110) for tooth #13 and #14 provided by an out-of-
network (OON) provider on April 2, 2022, and April 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the provider told you they accepted your 
insurance, and your bill was supposed to be lower. 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. The Plan also says the denial for the pulp cap is correct, because pulp caps 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, pulp caps are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for pulp caps (D3110) for tooth #13 
and #14. 
 
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 an evaluation (D0150), an intraoral (D0220), 
bitewings (D0274), and fillings (D2392) (D2393) for tooth #13 and #14 provided by an out-of-network (OON) 
provider on April 2, 2022, and April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group three power wheelchair with multiple power options. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that group 3 power wheelchairs are only covered 
when specific criteria are met. Group 3 power wheelchairs with multiple power options are covered for 
enrollees that require both power tilt and power recline. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee does not require power 
both tilt and power recline. The upgraded controller, harness and electronics cannot be covered as there is not a 
medical need to control more than two power options through the joystick. Based on this information, we 
decided that Medicare rules for coverage of a group three power wheelchair with multiple power options have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair 
with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's upper limb strength and function are therefore adequate for the enrollee to 
be able to control the power options using their own switches which are included in the allowance of these 
power options. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested electrical accessories are not medically necessary, as you do not have use of the upper 
extremity, and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies. 
 
You asked the Plan to pre-approve these services. You say that you need the device to sleep through the night. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a supplier must not dispense more than a three (3) - 
month quantity of supplies at a time. 
 
We looked at the file and Medicare rules. The services at issue are CPAP filters and full face masks for more 
than three month quantity at a time. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous 
positive airway pressure (CPAP) supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 10, 
2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental service. You say that your front tooth broke off into a sharp point. You 
say that this was a dental emergency. You also say that this should be covered. The Plan denied your request. 
The Plan says the limited oral evaluation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not 
among those covered under this benefit. Additionally, the record indicates that the plan sent a list of covered 
dental codes on January 31, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on May 10, 2022, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images obtained intra-orally or 
extra-orally (D0350) provided on May 18, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you did not want the 2D 
images done, just the free cleaning. The Plan denied your request. The Plan says the 2D images are not a 
covered service 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 2D 
oral/facial photographic images obtained intra-orally or extra-orally (D0350) X 4 provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an implant 
supported crown (D6065), provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an implant supported crown. You say that 
these services are medically necessary. The Plan denied your request. The Plan says the requested dental work 
are not covered 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 fabricated abutment (D6057) and an implant supported crown (D6065), provided by a participating 
provider.