Persius/hicric huggingface dataset:
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 at the in-network benefit. 
 You asked the Plan to pre-approve the out-of-network service at the in-network benefit. You say that the 
enrollee is prepared to have surgery. The Plan denied your request. The Plan says there are network providers 
available. 
 
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. 
 
Although the enrollees plan has a Point of Service (POS) benefit, authorization is still required to see any out 
of network providers. You are 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 at the in-network benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5110/D5120). 
 
You asked the Plan to pre-approve D5110 and D5120. You say that these should be covered. The Plan denied 
your request. The Plan says these services have bene correctly denied. 
 
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 Plan covers D5110 and 
D5120 when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D5110 and D5120 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dentures (D5110/D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit, electrocardiogram (EKG), and a 
vitamin B12 injection provided on July 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that medical records were provided to support 
the medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the annual wellness visit, electrocardiogram (EKG), and a vitamin B12 injection 
provided on July 22, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques provided by a chiropractor on 
August 1, 2023. 
 
You asked the Plan to pay for the manual therapy techniques. You say that you were told that the services were 
covered minus a $20 copay. The Plan denied your request. The Plan says the only covered chiropractic service 
is manual manipulation of the spine. 
 
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 manual therapy techniques provided by a chiropractor on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup (D2950) and a crown-porcelain/ceramic 
(D2740) provided on July 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The contract also says that a core buildup is not a covered service. Therefore, we decided that the Plan does not 
have to pay more for core buildup (D2950) and a crown-porcelain/ceramic (D2740) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques provided by a chiropractor on 
March 2, 2022. 
 
You asked the Plan to pay for the manual therapy techniques. You say that the claim should be reprocessed for 
payment. The Plan denied your request. The Plan says that manual therapy technique is not a covered benefit 
when billed by a chiropractor. 
 
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 manual therapy techniques provided by a chiropractor on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing - one to three 
teeth per quadrant (D4342) provided on September 6, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you had the same services performed the 
day prior and had no member responsibility. You also say that the next day you had the same procedure but the 
cost was only partially covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service $2,000 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. Specifically, 
the benefit for supplemental dental coverage is limited to $2,000 annually. The records show that the Plan paid 
$165 for claim number ending in 30073 for date of service provided on July 26, 2023. The records show that 
the Plan paid $1,074 for claim number ending in 19219 for date of service provided on July 31, 2023. The 
records show that the Plan paid $444 for claim number ending in 55680 for date of service provided on 
September 5, 2023. The records show that the paid $317 for claim number ending in 74611 for date of service 
provided on September 6, 2023. This means that the Plan paid $2,000 in total for dental services provided in 
2023. This exhausted the annual dental benefit allowance for the 2022 calendar year. Therefore, we decided 
that the Plan does not have to pay more for the periodontal scaling and root planing - one to three teeth per 
quadrant (D4342) provided on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with special features 
(E1399). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested bed is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says total electric hospital beds 
are noncovered because they are not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed with special features (E1399).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 16, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), a 
prefabricated abutment (D6056) and an abutment supported porcelain fused to metal crown (D6060) for tooth 
#12. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of the dental services. The Plan denied your request. The Plan says these services are not covered under 
your benefit 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 the 
surgical placement of implant body (D6010), a prefabricated abutment (D6056) and an abutment supported 
porcelain fused to metal crown (D6060) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that the previous partial denture was done wrong and 
when you attempted to go back and get it fixed, it got worse. You say when you chew, your gums bleed. 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 July 21, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the provider should have told you that they did 
not accept your insurance. 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 periodontal maintenance (D4910) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture- maxillary (D5110) provided on August 
23, 2023. 
 
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 August 8, 2022. 
Therefore, we decided that the Plan does not have to pay for complete denture- maxillary (D5110) provided on 
August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new Continuous Positive Air Pressure (CPAP) 
machine (E0601). 
 
You asked the Plan to pre-approve a new CPAP machine. You say that the new CPAP is medically necessary. 
The Plan denied your request. The Plan says insufficient information was provided to support this request. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The records provided do not document the age of the current CPAP the enrollee is using, or what if any damage 
the device has. Without this information, a replacement cannot be covered. Therefore, we decided that the Plan 
does not have to pre-approve a new Continuous Positive Air Pressure (CPAP) machine (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle (POV). 
 
You asked the Plan to pre-approve a heavy-duty POV. You say that you have difficulty walking with only a 
walker. You say that you need a wheelchair so you can enjoy life outside of your home and go to the grocery 
store. You also say that you have a lot of doctor appointments which are difficult to get to without a powered 
scooter. The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) may be covered 
when all the coverage criteria are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty POV have not been met. Specifically, the file shows that your weight does not 
qualify for the requested heavy-duty POV. The file also indicates that this device will primarily be for use 
outside the home. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power 
operated vehicle (POV).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 06, 2023, 
to September 09, 2023. 
 
You asked the Plan to pay for inpatient hospital services. You say that you are requesting reconsideration for 
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 inpatient hospital 
services provided on September 06, 2023, to September 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service August 2, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
32557. 
 
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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on August 
1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 comprehensive oral evaluation (D0150) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you didn't realize the provider was out of 
network.  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 on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on September 15, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that you needed hearing aids. You also say you went 
to the cheapest place you could find. The Plan denied your request. The Plan says member must receive care 
from a 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 the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on September 15, 2023.
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 a CGM. You say that the enrollee would benefit with this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been meet. 
 
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. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120). 
 
You asked the Plan to pre-approve D5110 and D5120. You say that you would like the Plan to approve these 
dentures. 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 
complete maxillary and mandibular denture (D5110 and D5120).