Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation. The Plan denied your request. The Plan says the requested trip exceeds the Plan's mileage 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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120) provided on May 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that in order to fix the plate you have to pay this 
amount and you cannot afford to pay for it. The Plan denied your request. The Plan says your benefit for the 
complete denture - mandibular $1,500 dollar limit was met. 
 
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 complete denture - mandibular was exhausted on date of service May 2, 2022. Therefore, we decided that the Plan does not have to pay for a complete denture - mandibular (D5120) 
provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140 and D7210) and the alveoloplasty 
(D7311) for tooth #5, #6, $9, #12, #13, and #14 provided on November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the in-network provider determined you needed 
dentures and the teeth that were removed were damaged. The Plan denied your request. The Plan says your 
benefit for the extractions has already been exhausted. Also, the denial of payment for the alveoloplasty is 
correct because it 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, certain limitations apply. The record 
shows your benefit for the extractions was exhausted on the date of service of November 15, 2022. The 
alveoloplasty is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have 
to pay for extractions (D7140 and D7210) and the alveoloplasty (D7311) for tooth #5, #6, $9, #12, #13, and 
#14 provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought you have remaining dental benefits 
to be used towards this date of service. The Plan denied your request. The Plan says your benefit for the 
requested service $5,000 limit was been met. 
 
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 service was exhausted on date of service June 9, 2022. Therefore, we 
decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on 
December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for bone replacement graft for ridge preservation - per site 
(D7953) provided on November 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were given a treatment plan with an 
estimate on it and thought insurance would cover more. 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 $1,000 
combined allowance for supplemental preventive and comprehensive dental services every year. Enrollee is 
responsible for any amount over and above the allowance amount. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $161 for date of service October 19, 2022, $190 for date of service October 31, 2022, and 
$649 for date of service November 28, 2022 ($161 + $190 + $649 = $1,000); therefore, your benefit was 
exhausted on date of service November 28, 2022. Therefore, we decided that the Plan does not have to pay 
more for bone replacement graft for ridge preservation - per site (D7953) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the implant removal (D6100) provided on December 7, 
2022. 
 
You asked the Plan to pay more for the dental service. You say that you were in pain from your implant 
breaking and you did not know that the Plan was at capacity. The Plan denied your request. The Plan says your 
combined allowance benefit for the year 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. On February 
8, 2022, the Plan paid $260.71 for dental services. On February 22, 2022, the Plan paid $1,271.18 for dental 
services. On March 22, 2022, the Plan paid $130.71 for dental services. On November 18, 2022, the Plan paid 
$146.40 for dental services. On November 22, 2022, the Plan paid $146.40 for dental services. On December 7, 
2022, the Plan paid $44.60 for the dental services. For the year of 2022 the Plan paid $2,000 ($260.71 paid + 
$1,271.18 paid + $130.71 paid + $146.40 paid + $ 146.40 paid + $44.60 paid) in dental services; therefore, the 
combined allowance benefit for the year of 2022 was exhausted on the date of service of December 7, 2022. 
Therefore, we decided that the Plan does not have to pay more for the implant removal (D6100) provided on 
December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on  
May 17, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider. 
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yupelri 175MCG/3ML solution (J7677). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot afford the medication. The 
Plan denied your request. The Plan says tiering exceptions are not allowed under Part B Medicare.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. You asked for a lower copay. 
This is called a tier exception. Tier exception reviews are NOT allowed under Part B. Part B is paying for this 
drug. This because its used in a nebulizer at home (or in assisted living). This is for a group of specific 
diagnoses, like the enrollees. Therefore, we decided that the Plan does not have to pre-approve Yupelri 
175MCG/3ML solution (J7677).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard frames, the progressive lens, and the anti-
reflective coating provided by an out-of-network provider on November 24, 2022.  
You asked the Plan to pay for the vision items. You say that your plan covers up to $300 and you want to be 
reimbursed for the eyeglasses. The Plan denied your request. The Plan says the services were not covered 
benefits. 
 
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 these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision items have not been met. Therefore, we 
decided that the Plan does not have to pay for the standard frames, the progressive lens, and the anti-reflective 
coating provided by an out-of-network provider on November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the lumbar 
spine (72100) provided on August 17, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the lumbar spine (72100) 
provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the deluxe frame, and the miscellaneous 
vision item provided on September 19, 2022. 
 
You asked the Plan to pay for the progressive lens, the deluxe frame, and the miscellaneous vision item. You 
say that you went for your annual eye exam, and it should be covered by the Plan. You say there is a benefit for 
eyeglasses with your plan. The Plan denied your request. The Plan says the services were not covered benefits. 
 
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 these services when covered by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens, the deluxe frame, and the 
miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to pay for the 
progressive lens, the deluxe frame, and the miscellaneous vision item provided on September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you meet all the 
requirements. The Plan denied your request. The Plan says the enrollee is not on a sliding scale and does not 
require frequent adjustments in insulin dosage. 
  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the supply allowance for the CGM. Our 
reviewer says that the supply allowance for the CGM is not medically necessary. Our physician reviewer found 
the A1c is 5.3% and the note says that the enrollee is off all diabetes medications; if this is incorrect and the 
enrollee is taking the 70/30, then they are taking it as a fixed dose 3 times a day without frequent adjustments 
so the criteria for coverage are not met which require multiple doses of insulin and frequent adjustments in 
doses based on blood glucose levels. 
 
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 supply allowance for the CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of gingival inflammation (D4346) 
provided on November 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider did not tell you the dental service 
was outside of a regular cleaning. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the scaling in presence of gingival inflammation 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 scaling in 
presence of gingival inflammation (D4346) provided on November 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on September 13, 2022, billed 
with code 71260. 
 
You asked the Plan to pay for radiological services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says code 71260 was billed with an invalid principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that a manifestation code cannot be billed as a 
principal diagnosis.   
We looked at the file and Medicare rules. In this case you billed code 71260 with a primary diagnosis of 
I25.83, which is a manifestation code. Based on this information, we decided that Medicare rules for coverage 
of radiological services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for radiological services provided on September 13, 2022, billed with code 71260.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on October 3, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says this item is not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
We looked at the file and Medicare rules. The medical records show that the enrollee received this device for 
treatment of low back pain. TENS is not considered reasonable and necessary for the treatment of chronic low 
back pain. Based on this information, we decided that Medicare rules for coverage of the TENS device have 
not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve 
stimulation (TENS) device (E0730) provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) and core buildup (D2950) for tooth 
#18 provided on November 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware at the time that your 
maximum was met, and the dental services were of medical need. The Plan denied your request. The Plan says 
your combined allowance benefit for the year 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. On February 
8, 2022, the Plan paid $130.71 for dental services. On March 21, 2022, the Plan paid $1,091.55 for dental 
services. On June 8, 2022, the Plan paid $228.48 for dental services. On November 18, 2022, the Plan paid 
$215.84 for dental services. On November 22, 2022, the Plan paid $333.42 for dental services. For the year of 
2022 the Plan paid $2,000 ($130.71 paid + $1,091.55 paid + $228.48 paid + $215.84 paid + $333.42 paid) for 
dental services; therefore, your combined dental benefit for the year of 2022 was exhausted on the date of 
service of November 22, 2022. Therefore, we decided that the Plan does not have to pay more for the crown 
(D2740) and core buildup (D2950) for tooth #18 provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215 x 2), drugs or medicaments dispensed in the office for home use (D9630), and the gingival 
irrigation-per quadrant (D4921 x 2) provided on December 9, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services provided are not 
covered under the supplemental policy. 
 
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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia in conjunction with operative or surgical procedures (D9215 x 2), drugs or medicaments dispensed 
in the office for home use (D9630), and the gingival irrigation-per quadrant (D4921 x 2) provided on 
December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided 
on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan denied this service stating it is a 
medical benefit. That when you have a dental issue you are treated by a dentist and not a medical doctor. 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. Additionally, this procedure is purely dental in nature and would not 
be covered under your medical benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunizations provided on September 15, 2022. 
 
You asked the Plan to pay for immunizations. You say that you are requesting reconsideration. 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 immunizations provided 
on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
December 14, 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 services 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, 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 2D 
oral/facial photographic image (D0350) provided on December 14, 2022.