Persius/hicric huggingface dataset:
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 requested CGM is medically necessary for the 
enrollee. 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 when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for more information from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5211) and a lower partial denture 
(D5212). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for the 
dental items requested in this case. 
 
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 has not provided relevant contract information to show 
often dentures are covered. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pre-approve an upper partial denture (D5211) and a lower partial 
denture (D5212). 
  
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 pre-approve a porcelain/ceramic dental crown for tooth number 9 
(D2740). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service November 4, 2021.  
  
 
 
 
 
Specifically, the Plans contract states that a porcelain/ceramic dental crown is covered once every 84 months 
per tooth. You previously received a dental crown for tooth number 9 on November 4, 2021, less than 84 
months prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the 
requested dental item at this time. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic dental crown for tooth number 9 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic Images 
(D0210) provided on May 1, 2023.  
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service April 5, 2022.  
  
 
 
 
 
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images is 
covered every 3 calendar years. You previously received this service on April 5, 2022, less than 3 years prior, 
which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the service provided in 
this case. Therefore, we decided that the Plan does not have to pay for the intraoral-comprehensive series of 
radiographic Images (D0210) provided on May 1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided by an out-of-network 
provider on April 24, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that you are appealing the denied claim. 
The Plan denied your request. The Plan says the out-of-network provider is a non-Medicare approved 
freestanding emergency facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
by an out-of-network provider on April 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on February 6, 2023, to 
February 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for skilled nursing facility care. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not authorized because Chiquita Houston-Armstrong, NP is 
a non-network provider who does not work with the enrollee's health Plan. 
 
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 skilled nursing facility care provided on February 
6, 2023, to February 25, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic footwear billed with codes A5500 (LT and RT) 
and A5512 (LT and RT) for date of service April 13, 2023. 
 
You asked the Plan to pay for the therapeutic footwear. You say that you have provided records and shipping 
information for these items. The Plan denied your request. The Plan says the documentation requirements have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order for the items provided in this case. While there is a 
prescription from the patient's doctor for therapeutic footwear, this prescription is specific to code A5513. 
There is no order for the two codes being billed in this case. 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 therapeutic footwear billed with codes A5500 (LT and RT) and A5512 (LT and RT) for date of 
service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you wanted a second opinion. The Plan denied 
your request. The Plan says you can receive the medically necessary care within network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental service. You say that the guard is medically necessary because 
you grind your teeth which gives you headaches. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the occlusal guard 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 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #18. 
 
You asked the Plan to pre-approve the dental service. You say that you are requesting approval for the implant 
body. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because dental implants and all associated services 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) for tooth #18.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour blood glucose kit. 
 
You asked the Plan to pre-approve the blood glucose kit. You say that your previous equipment stopped 
working and your doctor says you need the equipment and if there is a specific brand that you must use you 
would like the Plan to let you know. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose kit. Therefore, we decided that the Plan does not have to pre-approve a Contour blood 
glucose kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service January 27, 2020.  
  
 
 
 
 
Specifically, the Plans contract states that complete and partial dentures are covered once every 60 months. 
You previously received an upper and lower partial denture on January 27, 2020, less than 60 months prior, 
which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the dental items 
requested in this case at this time. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent medical transportation rides. 
 
You asked the Plan to pre-approve additional non-emergent medical transportation rides. You say that you 
need to be approved for more rides or your health is going to be severely compromised. The Plan denied your 
request. The Plan says your requests for rides in addition to the 24 one-way rides you are covered for exceeds 
the benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent medical transportation rides.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120), a maxillary 
complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the previous dentist kept the prothesis. You 
also say that the previous dentist referred you to another place. 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 June 10, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120), a maxillary 
complete denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #1 provided on January 3, 
2022. 
 
You asked the Plan to pay more for the dental service. You say that you should not have to make a payment a 
year and a half later after the initial payment because of the Plan's mistake. The Plan denied your request. The 
Plan says your annual dental maximum 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. The record 
shows the Plan paid $3,145 for dental services on January 3, 2022. On March 7, 2022, which was processed 
prior to the claim for January 3, 2022, the Plan paid $1,355 for dental services. For the year of 2022 the Plan 
paid $4,500 ($3,145 paid + $1,355 paid) for dental services; therefore, your annual dental maximum benefit for 
the year of 2022 was exhausted on the date of service of January 3, 2022. Therefore, we decided that the Plan 
does not have to pay more for a crown (D2740) for tooth #1 provided on January 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service May 19, 
2021. 
 You asked the Plan to pay for procedure code 12002. You say that this code was a separately identifiable 
service and should be paid. The Plan denied your request. The Plan says payment for code 12002 is bundled 
into payment for code 28490-54-T5. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 12002 
is a column II code to column I code 28490-54-T5. This claim has not been billed with an appropriate modifier 
to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12002 billed for date of service May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 additional rides. 
 
You asked the Plan to pre-approve 40 additional rides. You say that you had back surgery, and have to see 
many specialists. The Plan denied your request. The Plan says the request for additional rides exceeds the 
benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one way rides trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 40 additional rides.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve surgical placement of implant body. 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 pre-approve 
surgical placement of implant body (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing (82607, 82746) provided on February 
5, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the diagnosis codes from the referring 
provider were received late. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory testing was not filed until April 6, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the laboratory testing (82607, 82746) provided on February 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 22, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting a review of the denied 
claim. 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 skilled nursing facility 
provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on June 12, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment for cavities and a crown replacement. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
dental 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve treatment 
for cavities and a crown replacement.