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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral, 
comprehensive series of x-rays (D0210), a two dimensional oral/facial photographic image (D0350), and a 
panoramic radiographic image (D0330) provided on September 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says your benefit for a comprehensive oral evaluation (D0150), an intraoral, 
comprehensive services (D0210) and a panoramic radiographic image (D0330) has already been exhausted. 
The Plan also says that a two dimensional oral/facial photographic image (D0350) is excluded from this 
benefit. 
 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 a comprehensive oral evaluation (D0150), an intraoral, comprehensive services (D0210) 
and a panoramic radiographic image (D0330) were exhausted on date of service April 6, 2023. The record also 
shows that a two dimensional oral/facial photographic image (D0350) is excluded from this benefit. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral, 
comprehensive series of x-rays (D0210), a two dimensional oral/facial photographic image (D0350), and a 
panoramic radiographic image (D0330) provided on September 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the surgical placement of an implant 
body: endosteal implants (D6010 x 2) and the panoramic radiographic image (D0330) provided on June 20, 
2023. 
 
You asked the Plan to issue additional payment for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that your benefit 
for the services 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 services provided was exhausted on date of service June 20, 2023. Specifically, the 
Plans contract states that the dental benefit includes coverage for $1,500 every year for non-Medicare covered 
preventive dental services and non-Medicare covered comprehensive dental services combined. The record 
shows that the Plan previously issued payment in the amount of $1,500 ($50 + $619 + $831) for dental services 
provided in the 2023 calendar year. Therefore, you have exhausted the allowable benefit for the services 
provided in this case. Therefore, we decided that the Plan does not have to issue additional payment for the 
surgical placement of an implant body: endosteal implants (D6010 x 2) and the panoramic radiographic image 
(D0330) provided on June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the custom inserts were for your painful heal spur 
and they were medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on July 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that you did not know you need to check with the Plan. 
You also say you thought your optometrist referred you so you could make an appointment to see the specialist. 
The Plan denied your request. The Plan says that this is not a covered by the vision Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for an office visit by a contract provider. The file does not show that the Plan provided 
notice that an office visit would not be covered. Under Medicare rules, this means an office visit is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for an office visit provided on July 24, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the gingivectomy (D4211), bone graft at time of 
implant placement (D6104) and removal of residual tooth roots (D7250) provided on August 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you developed an infection and required a 
bone graft. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental plan and 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. 
Additionally, though the Plan offers a dental benefit in excess of Medicare coverage D4211 and D6104 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the 
gingivectomy (D4211), bone graft at time of implant placement (D6104) and removal of residual tooth roots 
(D7250) provided on August 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (73660, 99283) provided on 
August 5, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
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 an emergency room (ER) visit (73660, 
99283) provided on August 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system (36247). 
 
You asked the Plan to pre-approve selective catheter placement, arterial system. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary because your records 
show the interventional procedure for which the catheter placement is being requested is not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
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 selective catheter placement, arterial 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an 
experimental technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have 
demonstrated possible short-term safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement, arterial system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve selective catheter placement, arterial system (36247).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Zoster (shingles) vaccine provided on September 6, 2023. 
 
You asked the Plan to pay for vaccination for a shingles vaccine. You say that you did not receive a Shingles 
vaccine, but a flu shot. The Plan denied your request. The Plan says the vaccination for Shingles is not a 
covered service.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccination for 
Shingles. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to vaccination for 
Shingles. Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine provided on 
September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on June 30, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that these services were medically 
necessary. 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 chronic care 
management services provided on June 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transport services received on April 20, 2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary as there were no network providers available. The Plan denied your request. The Plan says the 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergent transport services received on April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator 
(0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart implantable pulse generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says there are not enough studies on Optimizer 
Smart pulse generator to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
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 Optimizer Smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found cardiac contractility modulation systems remain the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit.  
 
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 Optimizer Smart implantable pulse generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator 
(0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99203) and the x-ray exam 
of the cervical spine (72052) provided on September 9, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not covered by Medicare or the Plan.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the office visit (99203) and the x-ray exam of the 
cervical spine (72052) provided on September 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions and gingival irrigation with a 
medicinal agent (D1330, D4921) provided on August 9, 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions and gingival irrigation with a medicinal agent (D1330, D4921) provided on August 9, 
2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the hearing aid (V5298) purchased on July 17, 2023. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says that the hearing aid in this case is 
not payable as it was purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider. 
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have been met. Specifically, the Plans contract states that hearing aids must be purchased 
from the Plans select hearing aid provider. The record shows that the hearing aid in this case was purchased 
from the Plans select hearing aid supplier. Therefore, we decided that the Plan has to issue reimbursement for  
the hearing aid (V5298) purchased on July 17, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs from May 11, 2023, to May 15, 
2023. 
 
You asked the Plan to pay for the medication. You say that you cannot pay for the medication. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs from 
May 11, 2023, to May 15, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultraviolet light therapy system (E0691) provided on May 
18, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that this item was medically 
necessary. 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 relevant medical records which support medical necessity for the supplies provided in this case. Records show the plan confirmed with the enrollee that they did not request this item. 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 an ultraviolet light therapy system (E0691) provided on May 
18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs on August 21, 2023. 
 
You asked the Plan to pay for the medication. Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs on 
August 21, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameters provided on 
February 21, 2023. 
 
You asked the Plan to pay for remote monitoring of physiologic parameters. You say that the enrollee was in a 
nursing home at the time the services were rendered. 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 remote monitoring of 
physiologic parameters provided on February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from March 1, 2023, through 
March 7, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs from 
March 1, 2023, through March 7, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87481, 87798, 87653, 87640, 87651, 87641, 
87563, 87500) provided on May 18, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing (87481, 87798, 87653, 87640, 87651, 87641, 87563, 87500) provided 
on May 18, 2023.