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

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and electronic connection. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered and an electrical connection device described by code E2310 or 
E2311 is non-covered  if the sole function of the connection is for a power seat elevation. The rules say that an 
expandable controller with harness is used to control multiple power options. 
 
We looked at the file and Medicare rules. The requested power seat elevation system and electronic connection 
are not covered. The expandable controller with harness is not needed to control the approved power switches. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable 
controller with harness, and electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
and electro connect (E2311). You say that the requested expandable controller (E2377), expandable controller 
harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick are medically necessary. The Plan denied your request. The Plan says the requested 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control 
power tilt, recline and power elevating leg rests through the joystick are not medically necessary. 
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), and electro connect (E2311). Our reviewer says that the requested 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control 
power tilt, recline and power elevating leg rests through the joystick are not medically necessary. Our physician 
reviewer found the member has a neurologic disorder with functional deficits.  He meets criteria for use of a 
power mobility device.  The requested accessories are not medically necessary as he does have use of his left 
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 an expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100, 99140) provided on September 
30, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT codes 99100 and 99140 have a status indicator of B. This means that the 
payment for 99100 and 99140 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (99100, 99140) provided on 
September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676), provided on 
October 13, 2020. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676), provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
December 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have always had 2 dental check ups per 
year covered by your insurance. You also say that you were never informed that only one visit is covered. The 
Plan denied your request. The Plan says 1 oral exam is covered per calendar year. The Plan says that 1 cleaning 
are covered per calendar year. The Plan also says that the frequency limits have been exceeded. 
 
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, 
the frequency limits have been exceeded. The record shows that the Plan paid for an oral exam and prophylaxis 
that you received on June 28, 2021. Therefore, we decided that the Plan does not have to pay for the oral exam 
(D0120) and prophylaxis (D1110) provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on September 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010) for 
tooth #18, #19, #28, #30 and #31. 
 
You asked the Plan to pre-approve a surgical placement of an implant body. You say that you do not agree with 
the denial. The Plan denied your request. The Plan says this service is not covered under your Medicare 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 placement of an implant body (D6010) for tooth #18, #19, #28, #30 and #31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 9, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find 
that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase complete upper denture (D5710), rebase 
complete lower denture (D5711), and prefabricated abutments (D6056) for teeth # 22 and 27. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says rebase of upper denture is not listed as a covered service. The Plan says that rebase 
of lower denture is not listed as a covered service. The Plan also says that prefabricated abutment is not listed 
as a covered service either. 
 
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 rebase of upper and 
lower dentures, and prefabricated abutments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve rebase complete upper denture (D5710), rebase complete lower denture (D5711), and prefabricated abutments (D6056) for teeth # 22 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants represented by codes D6010 and 
D6999. 
 
You asked the Plan to pre-approve the dental implants. You say that you have had a problem with your 
dentures for years. You say that they push on a tooth, and you are losing sensitivity. You say that you cannot 
eat properly with the dentures. You say that you need to eat properly because of other diseases. You say that 
you are losing weight and bone structure. The Plan denied your request. The Plan says dental implants are not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants represented by codes D6010 and D6999.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
November 4, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the staff advised you that 
they received approval from the Plan for the services. The Plan denied your request. The Plan says your 
benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says 
that when you contacted the Plan you were only provided with in-network dentists, and you did not inquire 
about x-rays. 
 
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, full mouth or panoramic x-rays are 
limited to one procedure code every three years. The record shows that you received a complete series of 
intraoral x-rays (D0210) on July 11, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) 
provided on November 4, 2021.  
 
Your complaint about being misled by the providers staff 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection. 
 
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 covered. 
The Plan must follow Medicare rules. Medicare rules say that an electronic connection is used to control 
multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the electronic connection is not needed to control 
the approved power switches. 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 an electronic 
connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) provided by an our-of-
network provider on December 7, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D2332 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2332) provided by an out-of-network on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regenerations (D4266). 
 
You asked the Plan to pre-approve the guided tissue regenerations. The Plan denied your request. The Plan says 
this service is 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 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 
guided tissue regenerations (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement dentures. 
 
You asked the Plan to pre-approve the dental items. You say that your dentures are broken. You also say that 
you need new ones. The Plan denied your request. The Plan says dentures 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested replacement dentures are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
replacement dentures.
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 maxillary denture and complete mandibular denture. You say 
that you cannot wait the 5 years to get a new plate. 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 
August 17, 2021 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828) endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) 
endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic 
sensor(s), any type (L5856). 
You asked the Plan to pre-approve a K3 microprocessor knee. You say that the proposed device is the least 
level of technology available to safely meet the enrollee's functional needs. The Plan denied your request. The 
Plan says a microprocessor knee exceeds the enrollee's needs. 
 
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 a K3 microprocessor knee. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation does not describe the patient at a K3 level of 
function to justify utilization of a K3 knee prosthesis at this time. There was also insufficient report of the 
patient running or jogging on a regular basis or walking for long distances or on technical, slippery, or steep 
surfaces to justify this request. Therefore, the records do not meet Medicare coverage criteria for the above 
request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 microprocessor knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828) endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) endoskeletal knee-
shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) endoskeletal 
knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any 
type (L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish (D1208) 
provided on October 21, 2021. 
 
You asked the Plan to pay for the topical application of fluoride excluding varnish. The Plan denied your 
request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride excluding varnish (D1208) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral drugs (D9630) provided by a participating provider on 
October 18, 2021. 
 
You asked the Plan to pay for oral drugs. You say that you do not understand why this was denied. The Plan 
denied your request. The Plan says D9630 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral drugs 
(D9630) provided by a participating provider on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the fluoride (D1208), and 5 additional 
periapical x-rays (D0230) provided on November 30, 2021. 
 
You asked the Plan to pay the in network rate for fluoride and 5 additional periapical x-rays. You say that you 
were referred to this provider by a plan representative. You say that you have no means to pay this bill. You 
also say that you would not have gone to this dentist if you had known it would not be covered. The Plan 
denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the 
frequency limit has been exceeded. The Plan also says that fluoride 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray 
that you received on the date of service in this case. Additionally, fluoride is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay the in network rate for the fluoride (D1208), and 5 additional 
periapical x-rays (D0230) provided on November 30, 2021.