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

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 30, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you are allowed 3 cleaning per year and this 
claim should not be 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 your benefit for the requested item or service was exhausted on the date of service of September 09, 
2022. Records show the Plan paid for periodontal maintenance on January 3, 2022, March 24, 2022, and 
September 9, 2022. The claim for September 9, 2022, was received and paid prior to the Plan receiving the 
claim for June 30, 2022. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on June 30, 2022.
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 the LDCT is medically necessary. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 meet the age criteria of being 
between the age of 50 to 77 years old. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 continuous glucose monitor. You say that the patient is 
unwilling at this time to try injectables and was not checking his blood sugar consistently. The Plan denied 
your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 continuous glucose monitor. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2 continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complicated suture (D7911), a bone graft (D6104), 
and a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve a complicated suture, a bone graft, and a guided tissue regeneration. 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 
complicated suture (D7911), a bone graft (D6104), and a guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures are medically necessary for 
you to be able to eat. The Plan denied your request. The Plan says the denial of authorization for these services 
is correct, because dentures 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 pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the glucose monitoring services provided 
on June 02, 2022. 
 
You asked the Plan to waive the copayment for the glucose monitoring services. You say that your copayment 
for the services should be $0. 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 $10 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $10 copayment for the glucose monitoring services. This item/service falls 
within the outpatient diagnostic tests 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 
the glucose monitoring services provided on June 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for medical supplies, outpatient diagnostic tests 
and an outpatient hospital surgery provided on May 13, 2021, to August 10, 2021. 
 
You asked the Plan to waive the cost share for medical supplies, outpatient diagnostic tests and an outpatient 
hospital surgery. You say that you disagree with the cost share. 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 20% 
coinsurance a $150 copayment per visit and a $390 copayment for outpatient diagnostic test/surgical supplies/Medicare diagnostic services, outpatient surgery/Medicare covered surgery.  
 
You have been asked to pay a 20% coinsurance for outpatient diagnostic test/surgical supplies a $150 
copayment per visit for outpatient diagnostic test/Medicare diagnostic services and a $390 copayment for 
outpatient surgery/Medicare covered surgery. The total allowed amount for medical supplies is $173.10. You 
are being asked to pay $34.62 ($173.10 x 20% = $34.62). The total amount for the diagnostic test is $450 ($150 
x 3 test = $450). The amount you are being asked to pay for the outpatient surgery is $21.60 which is less than 
the required amount of $390. The total amount for all services is $506.22 ($450 + 21.60 + 34.62 = $506.22). 
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 cost share for medical supplies, outpatient diagnostic tests and an outpatient 
hospital surgery provided on May 13, 2021, to August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 12 and 13 
(D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you are aware D2740 tooth #12 and 13 is 
only covered once every 5 years but you need your teeth repaired. 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 5, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #'s 12 and 
13 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies. 
 
You asked the Plan to pre-approve diabetic supplies. You say that you would like the Plan to approve these 
supplies. The Plan denied your request. The Plan says enrollees must use diabetic supplies from a preferred 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that enrollees must use preferred providers to 
obtained diabetic supplies.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve diabetic supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on September 6, 2022. 
 
You asked the Plan to pay for the dental 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. 
 
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 February 28, 2022 and 
March 17, 2022. The Plan has indicated that the provider wrote off the charge. Therefore, we decided that the 
Plan does not have to pay for a periodic oral evaluation - established patient (D0120) provided on September 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your partial. 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, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), an implant 
supported crown (D6066), and a bone replacement graft (D7953) for tooth #8 to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve a custom 
fabricated abutment (D6057), an implant supported crown (D6066), and a bone replacement graft (D7953) for 
tooth #8 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that the tooth is fractured and needs a crown. 
The Plan denied your request. The Plan says that the crowns are not covered benefit when it is to restore 
damage due to attrition, abrasion, erosion, or abfraction. 
 
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. Specifically, the Plan did not provide us with medical records. Without this 
necessary documentation, the Plan has not substantiated their denial reason Therefore, we decided that the Plan 
has to pre-approve crowns (D2740) for tooth #8 and #9.  
 
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 caries susceptibility tests (D0425), and adjunctive pre-
diagnostic test (D0431), provided on October 25, 2022. 
 
You asked the Plan to pay for caries susceptibility tests and adjunctive pre-diagnostic test. You say that you 
believe the Plan should 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 pay for caries 
susceptibility tests (D0425), and adjunctive pre-diagnostic test (D0431), provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve a bone graft. You say that you would like the Plan to reconsider approval 
for these services. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 
bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim upper partial denture (D5820). 
 
You asked the Plan to pre-approve the dental service. You say that an exception should be made because you 
lost your 2 front teeth. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the interim upper 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim upper partial denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. You say that you need these dental implants. The Plan 
denied your request. The Plan says dental implants are not covered. 
 
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 
dental implants.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided from August 25, 2022, to August 29, 
2022. 
 
You asked the Plan to pay for wound care. You say that this should be covered. The Plan denied your request. 
The Plan says the 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 August 21, 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 wound care provided 
from August 25, 2022, to August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power mobility device provided on June 04, 2022, to 
September 19, 2022. 
 
You asked the Plan to pay for power mobility device. 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 power mobility device 
provided on June 04, 2022, to September 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing provided on March 2, 2022. 
 
You asked the Plan to pay for testing. You say that this should be covered. The Plan denied your request. The 
Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for testing provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory diagnostic testing (D0417), analysis of saliva 
sample (D0418), the periodontal scaling and root planing (D4341), gingival irrigation (D4921), and the 
unspecified periodontal procedure (D4999) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the dental services would be 
covered by your dental plan. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the laboratory diagnostic testing, analysis of saliva sample, the periodontal scaling 
and root planing, gingival irrigation, and the unspecified periodontal procedure 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 the 
laboratory diagnostic testing (D0417), analysis of saliva sample (D0418), the periodontal scaling and root 
planing (D4341), gingival irrigation (D4921), and the unspecified periodontal procedure (D4999) provided on 
October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit, and an x-ray 
provided on August 9, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist visit and an x-ray. You say that you do 
not understand why you have a second copay when both appointments were on the same day. 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 s $35 x-
ray copayment and a $35 specialist visit copayment ($35 x-ray copayment + $35 specialist visit = $70). 
 
You have been asked to pay a $70 copayment for a specialist visit and an x-ray. This item/service falls within 
the physician/practitioner services, including doctor's office visits and outpatient diagnostic tests and 
therapeutic services and supplies 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 an in-network specialist visit, 
and an x-ray provided on August 9, 2022.