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

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
for tooth number 8 and a therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation (D7953) for tooth number 8 
and a therapeutic parenteral drug (D9610). You say that even though the services are not covered, this is a 
medical necessity. You also say that your mouth hurts and you have lost a lot of weight for not being able to 
eat. The Plan denied your request. The Plan says this service is not covered under your benefit package 
 
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 bone 
replacement graft for ridge preservation (D7953) for tooth number 8 and a therapeutic parenteral drug (D9610).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health behavior assessment provided on August 12, 2022. 
 
You asked the Plan to pay for the health behavior assessment. You say that you were unaware of the additional 
charge to see this provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the health behavior 
assessment provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 11 miles. 
 
You asked the Plan to pre-approve an additional 11 miles. You say that you live in a rural area and have no 
transportation. The Plan denied your request. The Plan says your benefit only allows 50 miles. The Plan also 
says that you have exceeded your benefit limit 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles for each one-way trip trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 11 miles.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says the enrollee has a tobacco smoking history of 16.5 pack 
year. Therefore, the enrollee does not meet NCD criteria for a LDCT. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
  We reviewed the file and the Medicare rules. We find that the enrollee does not have a tobacco smoking history 
of at least 20 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth number 9, a maxillary 
partial denture (D5213) for tooth number 10, and a partial mandibular denture (D5214) for tooth number 21. 
 
You asked the Plan to pre-approve the dental services. You say that you are not able to eat anything other than 
soup. The Plan denied your request. The Plan says your benefit for a maxillary partial denture (D5213) for 
tooth number 10, and a partial mandibular denture (D5214) for tooth number 21 has already been exhausted. 
The Plan also says that a core buildup (D2950) for tooth number 9 is not covered benefit 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, certain limitations apply. The record 
shows that core buildup (D2950) is excluded from the Plan benefit. The record also shows that your benefit for 
a maxillary partial denture (D5213) for tooth number 10, and a partial mandibular denture (D5214) for tooth 
number 21 was exhausted on date of service January 6, 2020. Therefore, we decided that the Plan does not 
have to pre-approve core buildup (D2950) for tooth number 9, a maxillary partial denture (D5213) for tooth 
number 10, and a partial mandibular denture (D5214) for tooth number 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a benefit exception for two additional pairs of glasses 
beyond the yearly allowance. 
 You asked the Plan to pre-approve a benefit exception for two additional pairs of glasses beyond the yearly 
allowance. You say that you had a concussion in January and have nerve damage in your brain that goes to 
your right eye. You also say that it needs to be corrected with prism glasses. The Plan denied your request. The 
Plan says you are not eligible for new eyewear until June 03, 2023. The member last received eyewear on June 
03, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the lenses and one pair of eyeglass frames or contact lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that covered vision services routine eyewear 
includes the lenses and one pair of eyeglass frames or contact lenses every year. The record shows that you 
exhausted this benefit on June 3, 2022. Based on this information, we decided that the Plan's rules for coverage 
of a benefit exception for two additional pairs of glasses beyond the yearly allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a benefit exception for two additional pairs of 
glasses beyond the yearly allowance.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve the personal care services. You say that you are appealing the denial for 
home care services as the enrollee is with acute decompensated heart failure. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture (D9120) provided on August 22, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was necessary because the 
provider had to remove the bridge to extract the tooth. The Plan denied your request. The Plan says the denial 
of payment for this service is correct, because a fixed partial denture is 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, 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 fixed 
partial denture (D9120) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management to be provided by an OON provider. 
 
You asked the Plan to pre-approve pain management. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the enrollee must receive care from a network provider. 
 
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 
pain management to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluation - new/established 
patient (D0150), intraoral - complete series of radiographic images including bitewing (D0210) and 
prophylaxis  adult (D1110) provided on August 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you live in a small town and there are no 
in-network providers. 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 comprehensive oral evaluation - 
new/established patient (D0150), intraoral - complete series of radiographic images including bitewing 
(D0210) and prophylaxis  adult (D1110) provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiographic/surgical implant index (D6190), an 
endosteal implant (D6010), and an abutment supported crown (D6059), provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve radiographic/surgical implant index, an endosteal implant, and an abutment 
supported crown. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan 
says the rendered 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 
radiographic/surgical implant index (D6190), an endosteal implant (D6010), and an abutment supported crown 
(D6059), provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 7, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70480 is bundled into payment for code 70450. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 7, 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 abutment 
supported crown (D6059) provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that these services are medically necessary. 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) and an abutment supported crown (D6059) provided by a participating 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair (E1038). 
 
You asked the Plan to pre-approve a transport chair. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you have a similar DME in good and functional condition 
that is less than 5 years old. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a lightweight wheelchair (K0003). A lightweight wheelchair (K0003) serves the 
same purpose as a transport chair. Therefore, we decided that the Plan does not have to pre-approve a transport 
chair (E1038).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery for spinal cord stimulator to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve surgery. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the service can be provided by an in-network provider. 
 
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 
surgery for spinal cord stimulator to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code D7880 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code D7880. You say that the enrollee's benefits were verified and 
code D7880 is covered. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code D7880 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code D7880 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code D7880 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code D7880 billed for date of service July 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
26, 2022, to August 1, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $290 copayment per day for days 1-7 for inpatient hospital care. The total 
amount you are being asked to pay is $1,740 ($290 x 6days = $1,740). This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from July 26, 2022, to August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental 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 pre-approve a 
maxillary partial denture (D5213) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on October 11, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this was a routine eye exam so 
it should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medical eye exam. 
 
You have been asked to pay a $40 copayment for medical eye exam. This item/service falls within the Medical 
eye exam benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for medical eye exam provided 
on October 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health/hospice aide. 
 
You asked the Plan to pre-approve the home health/hospice aide. The Plan denied your request. The Plan says 
it is not a covered benefit under you plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health/hospice aide have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a 
home health/hospice aide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a binaural, digital hearing aid (V5258) provided on July 12, 
2022. 
 
You asked the Plan to pay for a binaural, digital hearing aid (V5258). You say that the Plan's benefit 
description under "in-network" is poorly detailed and easily misinterpreted. The Plan denied your request. The 
Plan says the hearing benefit is not covered if the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the enrollee contacts the Plan hearing first.  
 
 
  We looked at this physician's review, the file, and the Plan's rules. The record shows the EOC on page 4-27 
shows the phone number to call and the description of the hearing benefit. Based on this information, we 
decided that the Plan's rules for coverage of a binaural, digital hearing aid (V5258) have not been met. 
Therefore, we decided that the Plan does not have to pay for a binaural, digital hearing aid (V5258) provided 
on July 12, 2022.