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) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 CGM and related supplies. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires insulin use or low blood sugars. The enrollee is not using insulin and is not on a 
medication that typically causes low blood sugars. We are not told why the enrollee cannot use a glucometer 
with fingerstick blood glucose data instead of a CGM. While a CGM may help the enrollee, the coverage 
criteria are not met at this time. 
 
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 CGM and related supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on June 15, 2022, and July 1, 
2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused and endodontic therapy, molar 
tooth. The Plan denied your request. The Plan says your benefit for the requested services $3,500 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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $3,500 towards the cost of dental services provided in 2022. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and endodontic therapy, 
molar tooth (excluding final restoration) (D3330) provided on June 15, 2022, and July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard frames, the lens, the polycarbonate lens, and the 
anti-reflective coating provided on March 15, 2023. 
 
You asked the Plan to pay for the standard frames, the lens, the polycarbonate lens, and the anti-reflective 
coating. You say that you were never advised that your provider was out-of-network. The Plan denied your 
request. The Plan says the services are 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 provided 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 standard frames, the lens, the polycarbonate 
lens, and the anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to 
pay for the standard frames, the lens, the polycarbonate lens, and the anti-reflective coating provided on March 
15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-rays, and bitewing x-
rays (D0220, D0230, D0120, D0274) provided on March 15, 2023, by an out-of-network (OON) provider. 
 
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 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 a periodic oral evaluation, intraoral x-rays, and bitewing x-rays (D0220, D0230, D0120, D0274) 
provided on March 15, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling for tooth #10 (D2335) provided on April 20, 2023. 
 
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 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 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a filling for tooth #10 (D2335) provided on April 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the fitness rebounder and exercise ball (A9300) 
purchased on March 2, 2023. 
 
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 these items are not covered under 
the wellness allowance benefit.  
 
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 indicated that the exercise equipment purchased in this 
case was on January 1, 2022; however, the record shows that these items were purchased on March 2, 2023. 
The Plan has not forwarded the Evidence of Coverage contract for the 2023 calendar year. Therefore, we are 
unable to determine your eligibility for coverage of these items purchased. The Plan has not substantiated their 
denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to issue reimbursement 
for the fitness rebounder and exercise ball (A9300) purchased on March 2, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
December 1, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, the records did not include a physician order to verify the tests requested or medical records for 
review. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 provided on March 21, 2023. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for procedure code 99153 
provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/ general anesthesia (D9222, D9223), 
therapeutic parenteral drugs, two of more administrations, different medications (D9612), biopsy of oral tissue 
(D7285), bone replacement graft (D7953), collection and application of autologous blood concentrate (D7921) 
and infiltration of sustained release therapeutic drug  single or multiple sites (D9613) provided on January 26, 
2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep 
sedation/ general anesthesia (D9222, D9223), therapeutic parenteral drugs, two of more administrations, 
different medications (D9612), biopsy of oral tissue (D7285), bone replacement graft (D7953), collection and 
application of autologous blood concentrate (D7921) and infiltration of sustained release therapeutic drug  
single or multiple sites (D9613) provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6413 provided on February 13, 2023. 
 
You asked the Plan to pay for procedure code A6413. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code A6413 has a status indicator of E1. This code is not paid when submitted on outpatient 
claims. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code A6413 provided on 
February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic pontic (D6245) and the 
porcelain/ceramic retainer crowns (D6740 x 2) provided on April 11, 2023. 
 
You asked the Plan to pay for the dental 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 dental items provided are not a covered 
benefit under the supplemental 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 dental items provided are not 
among those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic pontic (D6245) and the 
porcelain/ceramic retainer crowns (D6740 x 2) provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (86706) related to end-stage renal 
disease (ESRD) provided on December 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (86706) related to end-stage renal disease (ESRD) provided on 
December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage of abscess - intraoral soft tissue 
(D7510), deep sedation/general anesthesia - first 15 minutes (D9222, D9223) provided on February 6, 2023. 
 
You asked the Plan to pay for incision and drainage of abscess - intraoral soft tissue and deep sedation/general 
anesthesia. You say that this should be covered. The Plan denied your request. The Plan says this is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for incision and drainage of abscess - intraoral soft tissue (D7510), deep sedation/general anesthesia - first 15 minutes 
(D9222, D9223) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite (D2391), bitewings (D0274), intraoral 
- periapical first radiographic image (D0220), - periapical each additional radiographic image (D0320), adult 
prophylaxis (D1110), a periodic oral evaluation (D0120), and a topical application of fluoride varnish (D1206) 
provided from February 2, 2023, to March 9, 2023. 
 You asked the Plan to pay for the dental services. You say that when the members benefits are verified on the 
Plan website, there is no mention of need for in-network providers. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by the members 
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 the member 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 resin-based composite (D2391), bitewings (D0274), intraoral - periapical first radiographic 
image (D0220), - periapical each additional radiographic image (D0320), adult prophylaxis (D1110), a periodic 
oral evaluation (D0120), and a topical application of fluoride varnish (D1206) provided from February 2, 2023, 
to March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, user 
adjustable heel height (L5990). 
 
You asked the Plan to pre-approve a prosthetic. You say that you are requesting reconsideration due to medical 
necessity. The Plan denied your request. The Plan says the requested heel height feature is not covered and will 
be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a user-adjustable heel height feature (L5990) will 
be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a prosthetic have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an addition to lower extremity prosthesis, user adjustable heel height (L5990).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, 2D oral/facial photographic 
image, periodontal scaling and root planing, alveoloplasty, and extractions (D0150, D0350, D4342, D4341, 
D7310, D7210 x2) provided on March 17, 2023, to April 14, 2023, by an out-of-network (OON) provider.  
 
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 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 a comprehensive oral evaluation, 2D oral/facial photographic image, periodontal scaling and root 
planing, alveoloplasty, and extractions (D0150, D0350, D4342, D4341, D7310, D7210 x2) provided on March 
17, 2023, to April 14, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by an in-network 
provider on May 9, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was the final post-operative 
office visit. 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 $35 
copayment for each in-network Medicare-covered visit with a specialist. 

You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 office visit provided by an in-network provider on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) provided on March 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that your previous denture was worn, and you had to 
get another pair. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete lower denture (D5120) on March 17, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 17, 2022. Therefore, we decided that 
the Plan does not have to pay for a complete lower denture (D5120) provided on March 17, 2023.