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

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110) and implant /abutment supported removable denture for edentulous arch  
mandibular (D6111). 
 
You asked the Plan to pre-approve an implant/abutment supported removable denture for upper and lower 
edentulous arch. You say that you would like these services covered. 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 an implant /abutment supported removable denture for edentulous arch  maxillary (D6110) and implant 
/abutment supported removable denture for edentulous arch  mandibular (D6111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to a lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system 
(L5981). 
 
You asked the Plan to pre-approve an advanced foot and ankle feature. You say that the prosthesis with an 
advanced foot is medically necessary. The Plan denied your request. The Plan says the request for a K3 foot 
exceeds the member's need and does not meet the Medicare criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say coverage is extended only if there is sufficient clinical 
documentation of functional need for the technologic or design feature of a given type of foot. 
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that notes from the physician do not show 
you as a K3 ambulator. Specifically, there must be clear documentation from the provider on why the parts are 
needed. Therefore, we decided that the Plan does not have to pre-approve an addition to a lower limb 
prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and an all-lower extremity 
prosthesis, flex-walk system (L5981).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the 13 additional simple extractions (D7140 x13). We decided that the 
Plan does not have to pay for the 3 alveoloplasties in conjunction with extractions (D7310 x3).  
 
You asked the Plan to pay for the 13 additional simple extractions and 3 alveoloplasties in conjunction with 
extractions. You say that you believe these services were medically necessary and should be covered. The Plan 
says that your dental maximum has been met. The Plan also says that your alveoloplasty benefit has been 
satisfied and the frequency limitation has been exceeded. 
 
We decided that the Plan has to pay for the 13 additional simple extractions (D7140 x13).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any medical records to show these services could not 
be covered as medical. Without this information we cannot determine that the Plan's coverage rules support the 
denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment in this case. 
Therefore, we decided that the Plan has to pay for the 13 additional simple extractions (D7140 x13).  
 
We also decided that the Plan does not have to pay for the 3 alveoloplasties in conjunction with 
extractions (D7310 x3). 
 
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. Alveoloplasty does not fall under a covered service for non-routine 
dental care. Therefore, we decided that the Plan does not have to pay for the 3 alveoloplasties in conjunction 
with extractions (D7310 x3). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377, E2311, E2313), custom 
fabricated seat and back cushions (E2609, E2617), power seat elevation feature (E2300), adjustable arm height 
option (E0973), and mounting hardware (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that this additional equipment is 
medically necessary in addition to the equipment that has already been approved. The Plan denied your request. 
The Plan says the criteria for coverage of these wheelchair accessories have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested equipment is subject to the criteria 
listed in the Medicare rules section. 
 
In this case, the power seat elevation feature (E2300) is statutorily non-covered by Medicare. Furthermore, the 
adjustable arm height option (E0973) is included in the payment for the power tilt seating system previously 
approved. The requested mounting hardware (K0108) is also not covered because the rules state that there is no 
separate payment for mounting hardware. 
 
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 expandable controller and custom 
fabricated seat and back cushions. Our reviewer says that the requested equipment is not medically reasonable 
and necessary. Our physician reviewer found the member is a 33-year-old female with a medical history 
including diabetes mellitus, hypertension and cerebral palsy with severe spasticity who has been authorized for 
a new group 3 power wheelchair with power tilt and recline. In this case, the member has a neurologic disorder with functional deficits.  Criteria for a power wheelchair are met. The requested cushions are not medically 
necessary as the standard cushions are adequate for support. The requested electrical accessories are not 
medically necessary as the member does 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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve expandable controller (E2377, E2311, E2313), custom fabricated seat and 
back cushions (E2609, E2617), power seat elevation feature (E2300), adjustable arm height option (E0973), 
and mounting hardware (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is unsure if the provider is in-
network. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network podiatrist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve a lower partial denture. You say that you lost your original denture and need 
a new one. The Plan denied your request. The Plan says you will exceed the frequency limit for this 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. The Plan covers a lower 
partial denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial 
denture was previously covered on July 17, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of a lower partial denture will be exceeded with the requested service. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on June 13, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
 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 the psychotherapy visit provided on June 13, 2021 
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 comprehensive oral evaluation - new or established 
patient (D0150) provided January 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you need a second opinion, and feel 
this should be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for 
this service. 
 
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 
comprehensive oral exam once every 36 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on September 22, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Wrex forearm support billed with code K0108. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device was not coded correctly. 
 
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 looked at the file and the rules. We find that the requested device has been approved using codes E2628 
and E2631. Providers shall not unbundle codes when there is a more comprehensive code that applies. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Wrex forearm support billed with code K0108.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the oral exam (D0120) and 
prophylaxis (D1110) provided on February 8, 2022. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that only $35.50 of your 
claim totaling $160 was paid. You say that you were expecting 50% of the billed amount to be paid. You say 
that The Plan denied your request. The Plan says the claim processed 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 the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided 
that the Plan does not have to reimburse an additional amount for the oral exam (D0120) and prophylaxis 
(D1110) provided on February 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl patches. 
 
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 self-administered drugs are not covered. 
 
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 Fentanyl patches.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable unilateral partial denture  one piece cast 
metal (including retentive/clasping materials, rests, and teeth), maxillary (D5282). 
 
You asked the Plan to pre-approve removable unilateral upper partial denture. You say that you need support 
for your dental crown. The Plan denied your request. The Plan says this service is 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 
removable unilateral partial denture  one piece cast metal (including retentive/clasping materials, rests, and 
teeth), maxillary (D5282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve service dog support. 
 
You asked the Plan to pre-approve service dog support. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 service dog support. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that it was determined that service dog support (S5199), to be 
provided by non-contracted provider, Solutran, Inc., was denied correctly. Based on additional research, the 
health plan requested medical records from the contracted provider. No medical records were received, and you 
were denied for procedure code S5199. The review has determined that the items/services at issue in this case 
are not medically reasonable or 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 service dog support have not been met. Therefore, we decided that the Plan 
does not have to pre-approve service dog support.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified orthodontic procedure, by report 
(D8999). 
 
You asked the Plan to pre-approve an unspecified orthodontic procedure. You say that you are in pain and need 
thi service. The Plan denied your request. The Plan says this service is 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 an 
unspecified orthodontic procedure, by report (D8999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
December 1, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the Plan provided you with the 
dental office where you were treated. You also say that you would like this service to be reconsidered for 
coverage. The Plan denied your request. The Plan says this service is 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.  
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 
adjunctive pre-diagnostic test (D0431) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81235, and 81321) provided 
on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81235, and 81321) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and limited oral 
evaluation - problem focused (D0140) provided December 14, 2021. 
 You asked the Plan to pay for the panoramic x-ray and limited oral exam. You say that the policy shows that 
you can see out-of-network providers. The Plan denied your request. The Plan says these services are not 
covered because the provider has opted out of Medicare. 
 
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 panoramic 
x-ray and limited oral exam when you see any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare.   
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the panoramic x-ray and limited oral exam have not been met. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and 
limited oral evaluation - problem focused (D0140) provided December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rear basket (K0108). 
 
You asked the Plan to pre-approve a rear basket. You say that this is necessary when the enrollee is moving 
items. The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  
 
Therefore, we decided that the Plan does not have to pre-approve a rear basket (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310), and an unspecified preventative 
procedure (D1999) provided by an out-of-network provider on March 11, 2021. 
 
You asked the Plan to pay for a consultation and an unspecified preventative procedure. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says this claim has been processed 
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, 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 a 
consultation (D9310), and an unspecified preventative procedure (D1999) provided by an out-of-network 
provider on March 11, 2021.