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

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6245, D6545) for teeth #23 and #24. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you have a removable prosthetic to replace this 
tooth, but food gets stuck in it and you would prefer a fixed one. The Plan denied your request. The Plan says 
the requested fixed bridge is not medically necessary, as there is no documentation to support that you cannot 
use a removable prosthesis. 
 
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 fixed bridge 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a fixed bridge. Our reviewer says that 
the Plan's criteria for a fixed prosthetic are not met in this case. Our physician reviewer found that you have an 
existing partial lower denture but are finding that food gets trapped around it. You would like a fixed appliance. 
The Plan does not allow for fixed bridgework where the use of a removable appliance is possible. The 
limitation specifically limits consideration of fixed bridgework to cases that involve a neurological disorder or some other physical disability that precludes the use of the removable appliance. There has been no showing of 
any disability that would indicate a need for a fixed appliance. It is also noted that the proposed abutment tooth 
has significant bone loss and would be an inadequate support for a bridge of any type, particularly a cantilever 
bridge due to excessive forces placed on the abutment. Given the Plan limitations, along with the poor quality 
of the proposed abutment, there would be no necessity for the requested bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a fixed bridge have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a fixed bridge (D6245, D6545) for teeth #23 and #24.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (99053) provided on November 21, 2021.  
You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says CPT code 99053 has a status indicator of B. 
 
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 CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (99053) provided on November 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says the coverage criteria are not met.

The Plan follows Medicare rules. Medicare rules say that a home ventilator is covered for the indications established in the applicable LCD.

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 home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests to confirm and provide severity. The enrollee's most recent arterial blood gas test (ABG), done after extubation in the hospital, showed a normal PaCO2. There is no ABG done as an outpatient while the patient is awake and stable, showing CO2 retention.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by participating providers on 
January 4, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told that these dentists were in-network. 
The Plan denied your request. The Plan says covered dental services are allowed by participating dentists only. 
 
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 dental 
services when the services are provided in-network.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by out-of-network providers on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze (A6216, A6219) provided on December 9, 2021. 
 
You asked the Plan to pay for gauze. You say that this should be covered. The Plan denied your request. The 
Plan says this is not separately 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 CPT codes A6216 and A6219 have a status indicator of P on the Physician Fee Schedule. This 
means that CPT codes A6216 and A6219 are not separately payable. Based on this information, we decided 
that Medicare rules for coverage of gauze have not been met. Therefore, we decided that the Plan does not have 
to pay for gauze (A6216, A6219) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable unilateral partial denture (D5282) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the removable unilateral partial denture. You say that you purchased dental rider 
which became effective on November 1, 2021, and this service should have been covered under the rider. The 
Plan denied your request. The Plan says this service is not a covered benefit 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 the 
removable unilateral partial denture (D5282) provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), an abutment 
supported crown (D6058), and an endosteal implant (D6010) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment, an abutment supported crown, and an 
endosteal implant. You say that you would like the Plan to approve and pay for this. The Plan denied your 
request. The Plan says the requested dental services 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), an abutment supported crown (D6058), and an endosteal implant 
(D6010) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), and bone 
replacement graft (D4263) provided on January 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the guided tissue regeneration and bone replacement graft are not listed as covered 
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 guided tissue regeneration and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the guided tissue regeneration (D4266), and bone replacement graft (D4263) provided 
on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 26. 
 
You asked the Plan to pre-approve a crown for tooth 26. You say that the crown is medically necessary to 
relieve the enrollee's pain and sensitivity. The Plan denied your request. The Plan says the enrollee 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 Plan's coverage rules apply in this case. The Plan covers a crown for 
tooth 26 once every five plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a crown for tooth 26 
was previously covered on February 3, 2022. Based on this information, we decided that the Plan's frequency 
limit for coverage of a crown for tooth 26 would be exceeded with the requested service. Therefore, we decided 
that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable calibrated tensioning socket system, 
thermoplastic elastomer socket rotation control mechanism, and untensioned/open socket circumference 
donning feature. 
 
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 code L5999 must not be used to bill for any 
features or functions included in the socket or addition codes. 
 
We looked at the file and Medicare rules. The services at issue were requested with code L5999. The services 
cannot be approved as requested under this code. Therefore, we decided that the Plan does not have to pre-
approve an adjustable calibrated tensioning socket system, thermoplastic elastomer socket rotation control 
mechanism, and untensioned/open socket circumference donning feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that this dental work is medically 
necessary. The Plan denied your request. The Plan says D2740 and D2950 are not medically necessary for 
tooth #8. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a crown and a 
core build-up when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown and a core build-up. Our 
reviewer says that this dental work is not medically necessary. Our physician reviewer found the documentation 
that was provided shows that the criteria for coverage has not been met for tooth #8. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown and a core build-up have not been met.  Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 7, 8, 9, and 10. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says that the x-rays do 
not show the teeth have decay or loss due to fracture involving more than 50% of the biting edge of the tooth. 
The Plan also says that there is no clinical evidence to support medical necessity. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
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 crowns. Our reviewer says that the 
documentation provided meets the criteria for coverage for crown restorations (D2740) for tooth #'s 7, 8, 9, and 
10. Our physician reviewer found the documentation indicates that tooth #'s 7, 8, 9, and 10 have defective 
restorations and recurrent caries. Our reviewer found that the placement of direct restorations would comprise 
more than 50% of the tooth structure and severely weaken these teeth. Our physician reviewer also found that 
the placement of crown restorations is medically reasonable and necessary to provide good long-term function. 
 
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 crowns have been met. Therefore, we decided that the Plan has to pre-
approve crowns (D2740) for tooth #'s 7, 8, 9, and 10.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
December 17, 2021. 
 
You asked the Plan to pay for a crown. You say that this was a non-surgical procedure. You say that you feel as 
though this should be covered. The Plan denied your request. The Plan says major restorative services are not 
covered a 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 crown 
(D2740) provided by a participating provider on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 23, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are not separately payable.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 23, 2021.
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) 
and resin-based composite - one surface, posterior (D2391) provided February 1, 2022. 
 
You asked the Plan to pay for the fillings. You say that you would have waited to have the services done if you 
had known that they would not be covered. The Plan denied your request. The Plan says you did not enroll in 
supplemental benefits in 2022, and these dental services are not covered under 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 pay for the resin-based composite - two surfaces, posterior (D2392) and resin-based composite - one surface, posterior (D2391) 
provided February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided October 20, 2021.

You asked the Plan to pay for the continuous glucose monitor. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. No detailed invoice was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride treatment (D1206). 
 
You asked the Plan to pay for the fluoride treatment. You say that the service should be covered. The Plan 
denied your request. The Plan says the service exceeds the frequency limitation of the member's plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you have exceeded the maximum 
frequency set for the requested service. Therefore, we decided that the Plan does not have to pay for the 
fluoride treatment (D1206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture, partial lower (D5866). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says overdenture 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, 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 
overdenture, partial lower (D5866).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics (D6245 x2). 
 
You asked the Plan to pre-approve the pontics. You say that you disagree with the Plan's denial because 95% of 
the work is already approved and due to this denial, the work is half done. You also say that you do not have 
the money to pay for these services. The Plan denied your request. The Plan says when crowns on implants are 
used as retainers for fixed bridge pontics, your benefit covers up to ten retainer crowns and retained pontics. 
The Plan also says that in this case there were 12 units requested, thus 2 two exceed the coverage maximum. 
 
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, pontics and retainer crowns are limited 
to up to a maximum of 10 units per year. The record shows that you were approved to receive five custom 
fabricated abutments (D6057 x5) and five abutment supported retainers (D6068 x5), and your pontics and 
retainer crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
two pontics (D6245 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete 
maxillary denture (D5110), and complete mandibular denture (D5120) provided on May 8, 2020 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, complete maxillary denture, and complete 
mandibular denture. You say that the provider that you received these services from does not deal with claims, 
and you would like to appeal these services. The Plan denied your request. The Plan says this claim was 
received after the timely filing limitations. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), complete maxillary denture (D5110), and complete mandibular 
denture (D5120) provided on May 8, 2020 by an out-of-network (OON) provider.