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

 
We decided that the Plan does not have to pay for a a crown and nitrous oxide/analgesia (D9230, D2740) 
provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the dental crown has already been 
exhausted. Coverage for the nitrous oxide/analgesia denied correctly as they do not fall within your dental 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 18, 2020. Therefore, 
we decided that the Plan does not have to pay for a a crown and nitrous oxide/analgesia (D9230, D2740) 
provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a partial lower 
denture (D5214), and an unspecified removable prosthodontic procedure (D5899). 
 
You asked the Plan to pre-approve the dental services. You say that you need your dentures replaced. The Plan 
denied your request. The Plan says your benefit for the dentures service has already been exhausted. The 
unspecified removable prosthodontic procedure 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, certain limitations apply. The record 
shows your benefit for the dentures was exhausted on dates of service February 21, 2019, and February 10, 
2022. Additionally, unspecified removable prosthodontic procedure is not a covered benefit. Therefore, we 
decided that the Plan does not have to pre-approve a complete upper denture (D5110), a partial lower denture 
(D5214), and an unspecified removable prosthodontic procedure (D5899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, bitewing x-rays, cone beam CT 
scan, and a dental consultation (D0140, D0270, D0380, D9310) provided on August 26, 2022, to September 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the limited oral evaluation and 
bitewing x-ray had already been exhausted. Coverage for the consultation and cone beam CT scan (D9310, 
D0380) denied correctly as they do not fall within your dental 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 13, 2022 
(D0140) and August, 17 2022 (D0170). Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation, bitewing x-rays, cone beam CT scan, and a dental consultation (D0140, D0270, D0380, 
D9310) provided on August 26, 2022, to September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) and rebase 
complete upper denture (D5710) provided on December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that your denture broke, and the dentist needed to 
repair it. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the unspecified preventive procedure and rebase complete upper denture are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 an 
unspecified preventive procedure (D1999) and rebase complete upper denture (D5710) provided on December 
8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9374 billed for date of service September 1, 
2022, to September 6, 2022. 
 
You asked the Plan to pay for procedure code S9374. 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 S9374 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9374 is not valid for Medicare purposes. 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 procedure code S9374 billed for date of service September 1, 2022, to September 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 2, 2022. 
 
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 that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence for the denial of 
payment for these laboratory services based on Medicare criteria. Therefore, we decided that the Plan has to 
pay for the laboratory services provided on September 2, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for a crown (D7240) provided on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a crown (D7240) provided on September 14, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on September 07, 2022. 
 
You asked the Plan to pay for rest home visit. You say that it is the responsibility of the facility to obtain 
authorization 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 rest home visit provided 
on September 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four over-the-counter (OTC) COVID-19 tests purchased 
on October 6, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that it is your understanding that as a member of 
this plan, you can obtain up to four rapid tests per month. The Plan denied your request. The Plan says your 
Medicare plan does not pay for OTC COVID-19 tests. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 tests are an OTC item. The Plan does not offer a supplemental benefit covering this service, as this 
is not currently required by Medicare. However, these tests can be obtained with participating providers and 
covered by Original Medicare when using your Medicare card rather than your Plan card. Therefore, we 
decided that the Plan does not have to pay for the four over-the-counter (OTC) COVID-19 tests purchased on 
October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NexWave (E0730), provided on July 20, 2022. 
 
You asked the Plan to pay for the NexWave. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation submitted did not include a valid physician order, Proof of 
Delivery, or a Delivery Ticket. 
 
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. The dates on the 
packing slip and delivery slip do not match the date of service. 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 the NexWave (E0730), provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride (D1206) and Periodontal 
scaling and root planning (D4341) provided on October 6 and 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told it would be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 your benefit for periodontal scaling and root planning (D4341) was exhausted on date of service May 
18, 2021. The record shows your benefit for topical application of fluoride (D1206) was exhausted on dates of 
service March 3, 2022, and June 14, 2022. Therefore, we decided that the Plan does not have to pay for topical application of fluoride (D1206) and periodontal scaling and root planning (D4341) provided on October 6, 
2022, and October 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopic services provided on September 25, 2022. 
 
You asked the Plan to pay for an endoscopic procedure. You say that hospice was revoked on September 23, 
2022, and then reinstated on September 30, 2022. You say that the enrollee was not enrolled in hospice on the 
date of service in question. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on September 23, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the endoscopic 
services provided on September 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from an IRF to improve overall 
functional mobility and safety prior to returning home. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require rehabilitation nursing or treatment by multiple therapies. 
Although you have had a functional decline from your baseline level of function and would benefit from 
occupational and physical therapy, you do not require the intensity of therapies provided in acute inpatient 
rehabilitation 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
November 18, 2022. 
 
You asked the Plan to pay for the CGM. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130) provided on 
October 25, 2022. 
 
You asked the Plan to pay for the maxillary immediate denture. You say that you attached a copy of the 
benefits summary showing dentures are covered at 100%. You also say that you would like this claim to be 
reviewed and processed accordingly. The Plan denied your request. The Plan says this service is not a covered 
expense under the enrollee's dental plan. The Plan also says that the enrollee did not contact the Plan prior to 
the date of service to verify benefits and provider eligibility. 
 
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 
maxillary immediate denture (D5130) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0140, D0220, D0230, D2330, D2331, 
D2332, D2335, D2391, D2392, D2393) provided on July 28, 2022, to September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 your benefit for the requested item or service was exhausted on date of service August 4, 2022. 
Therefore, we decided that the Plan does not have to pay for dental services (D0140, D0220, D0230, D2330, 
D2331, D2332, D2335, D2391, D2392, D2393) provided on July 28, 2022, to September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction, bone replacement graft, and the 
collection and application of autologous blood concentrate (D7953, D7140, D7921) provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a dental extraction, bone replacement graft, and the collection and application of autologous blood 
concentrate (D7953, D7140, D7921) provided on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing laboratory services provided on September 02, 
2022. 
 
You asked the Plan to pay for drug testing laboratory services. You say that the records attached support the 
services provided 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 drug testing laboratory 
services provided on September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on August 17, 
2022. 
 
You asked the Plan to pay for the occlusal adjustment (D9951). You say that you were informed it was covered 
and wouldnt have had it done if you would have known. The Plan denied your request. The Plan says the 
service code is not listed as 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 
occlusal adjustment (D9951) provided on August 17, 2022.