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

 
We decided that the Plan does not have to pre-approve crown  porcelain/ceramic substrate (D2740) for tooth # 
09, 11, 12, 14, 22, 23 and 29, endodontic therapy, anterior tooth (excluding final restoration) (D3310) tooth # 9 
and 23, core buildup, including any pins when required (D2950) tooth # 5, 9 and 23, retainer crown  porcelain 
fused to high noble metal (D6750) Tooth #6 and 8, pontic  porcelain fused to high noble metal, (D6240) 
Tooth #7 and prefabricated post and core in addition to crown (D2954) Tooth #23. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial for the 
requested services. 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. This benefit includes the 
requested crown  porcelain/ceramic substrate (D2740) and endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) but each are limited to one per calendar year. This benefit includes only those items and 
services specifically listed in your Plan contract. core buildup, including any pins when required (D2950), 
retainer crown  porcelain fused to high noble metal (D6750), pontic  porcelain fused to high noble metal, 
(D6240) and prefabricated post and core in addition to crown (D2954) are not covered under the Plans dental 
benefits. 
 
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 core 
buildup, including any pins when required (D2950) tooth # 5, 9 and 23, retainer crown  porcelain fused to 
high noble metal (D6750) Tooth #6 and 8, pontic  porcelain fused to high noble metal, (D6240) Tooth #7 and 
prefabricated post and core in addition to crown (D2954) Tooth #23. 
 
We looked at the file, the Plans rules, and Medicares rules. You have been pre-approved for covered D2740 
x1 and D3310 x1 on March 7, 2023. Therefore, these benefits were exhausted as of March 7, 2023. Therefore, 
we decided that the Plan does not have to pre-approve crown  porcelain/ceramic substrate (D2740) for tooth # 
09, 11, 12, 14, 22, 23 and 29, endodontic therapy, anterior tooth (excluding final restoration) (D3310) tooth # 9 
and 23.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for OON chiropractic care. You say that this should be covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic care provided on July 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full exam (D0150) and a full series of x-rays (D0210) 
provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should 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 the full exam was exhausted on date of service September 20, 2022, and your benefit for 
the full x-rays was exhausted on January 16, 2020.  Therefore, we decided that the Plan does not have to pay 
for a full exam (D0150) and a full series of x-rays (D0210) provided on November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on November 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan's website says that 4 oral evaluations 
are covered, and it makes no sense why payment was denied. 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 the Plan paid for a periodic oral evaluation on January 19, 2022, and May 5, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of May 5, 2022. Therefore, we 
decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on November 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial denture (D6930) provided on November 17, 2022. 
 
You asked the Plan to pay for partial denture. You say that this should be covered. The Plan denied your 
request. The Plan says this is not 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 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 partial 
denture (D6930) provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 2, 
2023. 
 
You asked the Plan to pay for the dental service. You say that this is the first time this year you got the service, 
and it should 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 the Plan paid for periodontal maintenance on April 18, 2022, and August 22, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of August 22, 2022, and the 
service would not be eligible again until April 18, 2023. Therefore, we decided that the Plan does not have to 
pay for the periodontal maintenance (D4910) provided on January 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 dental services provided by an out-of-network (OON) provider on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-ray (D0210) provided on November 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should 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 the requested item or service was exhausted on date of service November 18, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral x-ray (D0210) provided on November 
18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 27, 2022. 
 
 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice. 
You also say that the ambulance transport was for an injury related to a fall and not related to the patient's 
terminal illness. The Plan denied your request. The Plan says the enrollee was enrolled in hospice services on 
this date of service. Therefore, traditional Medicare is the primary payer for this date of service. 
 
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 November 27, 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 ambulance services 
provided on November 27, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to reduce the coinsurance for the denosumab injection provided on December 27, 
2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that the injection charge has increased. 
The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug 
obtained in a providers office or outpatient setting.  
 
The Plan says you must pay $270.12 for the injection. Based on the Plan contract, however, you cannot be 
asked to pay more than $265.79, which is 20% coinsurance of the allowed amount for the injection ($1,328.99 
allowed amount x 20% = $265.79). Therefore, we decided that the Plan has to reduce the coinsurance for the 
denosumab injection provided on December 27, 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: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 dental services provided by an out-of-network (OON) provider on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary to monitor your 
glucose levels. The Plan denied your request. The Plan says the Medicare criteria was not met. 
  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 case file included information from you stating that you are not 
on insulin with at least three daily injections. 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 pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on October 13, 2022. 
 You asked the Plan to pay for the cytopathology services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cytopathology services, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the cytopathology services provided on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex base denture including retentive clasps (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary that you receive 
the pink feature on your top partial. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the flex base denture including retentive clasps 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
flex base denture including retentive clasps (D5225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the CT of the chest. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT of the chest. Our reviewer says 
that the CT scan is not medically necessary. Our physician reviewer found that you have no apparent cardio-
pulmonary signs or symptoms. Clinical guidelines for the use of a chest CT have not been met based on review 
of the submitted clinical documentation. At this time a chest CT scan would not be considered medically 
reasonable and necessary for your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 14, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided 
on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) for tooth #7 provided on 
December 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went for an extraction, and you did not ask 
for the other procedures to be done. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the bone replacement graft 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) for tooth #7 provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth extractions (D7140) and a maxillary complete denture 
(D5110), provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you would be reimbursed. 
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 tooth extractions (D7140) and a maxillary complete denture (D5110), provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) and consult 
diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) 
provided on November 14, 2022, and November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the limited oral evaluation-problem focused 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 September 14, 2022. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) 
and consult diagnostic service provided by a dentist or physician other than the requesting dentist or physician 
(D9310) provided on November 14, 2022, and November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pin retention (D2951) provided on December 7, 2022. 
 
You asked the Plan to pay for D2951. You say that you believe a lost filling should be covered. The Plan 
denied your request. The Plan says D2951 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 pin 
retention (D2951) provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation, new or established (D0150) 
and re-cement or re-bond natural tooth crown (D2920) provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should 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 the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for comprehensive oral evaluation, new or established (D0150) and re-cement or re-bond 
natural tooth crown (D2920) provided on June 1, 2022.