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

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on May 
3, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that the provider's office 
wanted you to see an ophthalmologist to determine if there were other issues and a treatment. The Plan denied 
your request. The Plan says eye refractions are only covered by your plan if performed by a participating Plan 
vision provider and performed during a routine eye examination. 
 
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 they are a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover eye refractions during a routine 
examination. Diagnostic eye refractions are excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of a determination of a refractive state (92015) have not been met. Therefore, 
we decided that the Plan does not have to pay for a determination of refractive state (92015) provided on May 
3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), therapeutic 
parenteral drug, single administration (D9610), deep sedation/general anesthesia  first 15 minutes (D9222) 
and each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve the dental services represented by codes D7210, D9610, D9222 and D9223. 
You say that you need two teeth extracted and would like the Plan to cover it The Plan denied your request. 
The Plan says these services are not covered under the benefit package.   
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 an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210), therapeutic parenteral drug, single administration (D9610), deep 
sedation/general anesthesia  first 15 minutes (D9222) and each subsequent 15 minute increment (D9223).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 27, 2023. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered 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, the requested service is not among 
those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pre-approve the cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws; with or without cranium (D0367).
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 the requested items are not covered 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 requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teledentistry - synchronous; real-time encounter (D9995) 
provided on April 12, 2023. 
 
You asked the Plan to pay for teledentistry - synchronous; real-time encounter. 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 
teledentistry - synchronous; real-time encounter (D9995) provided on April 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you didn't 
have this service or were seen by a paramedic this day. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 2, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) 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 June 10, 2021.  
  
 
 
 
Specifically, the Plans contract states that one upper and lower partial denture is covered every 60 months. 
You previously received these dental items on June 10, 2021, less than 60 months prior, which were paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for the requested items in this case. Therefore, 
we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial dentures (D5214, D5213) provided on 
January 30, 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 maxillary 
partial dentures (D5214, D5213) provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre. 
 
You asked the Plan to pre-approve the FreeStyle Libre. You say that your family doctor wanted to put you on 
insulin but you refused. You also say that you cannot give yourself shots and to please approve your case. The 
Plan denied your request. The Plan says you are not receiving insulin and have not had documented 
hypoglycemic episodes so the CGM is not medically necessary and not covered by Medicare.  
 
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 you do not use insulin or have a 
history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for coverage 
of the FreeStyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided from August 3, 
2022, to August 31, 2022. 
 You asked the Plan to pay for the outpatient therapy services. 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. The rules say that outpatient rehabilitation claims must include one of 
the GN, GO, or GP modifiers. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the GP modifier for 
the outpatient physical therapy services provided. The claim shows modifier GO billed for all services. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient therapy services provided from 
August 3, 2022, to August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are being charged more than double what 
you were originally told. 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 September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided February 22, 2023. 
 
You asked the Plan to pay for D5899. You say that you are not satisfied with the level of care that you 
received. You say that they would not adjust your dentures. The Plan denied your request. The Plan says 
D5899 is not a covered 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, 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 an 
unspecified removable prosthodontic procedure (D5899) provided February 22, 2023. 
 The complete maxillary denture provided has been approved and paid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740), pontic - 
porcelain/ceramic (D6245), core buildup (D2950), crown - porcelain/ceramic (D2740), unspecified removable 
prosthodontic procedure (D5899), periodontal maintenance (D4910), gingival Irrigation - per quadrant (D4921) 
and topical application of fluoride varnish (D1206) provided on August 12, 2022, to October 25, 2022. 
 
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 these are not covered services. 
 
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 retainer 
crown - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245), core buildup (D2950), crown - 
porcelain/ceramic (D2740), unspecified removable prosthodontic procedure (D5899), periodontal maintenance 
(D4910), gingival Irrigation - per quadrant (D4921) and topical application of fluoride varnish (D1206) 
provided on August 12, 2022, to October 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 8, 2022, to 
September 6, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 8, 2022. The NOA was not received by the Plan until September 12, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 8, 2022, to September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you believe the custom orthotics would be 
beneficial to the enrollee's overall support and stability. 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 the enrollee does not suffer from diabetic foot disease, and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for the enrollees condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 03, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
January 03, 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 the CGM. 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 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 authorization 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: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) for tooth #30, the deep 
sedation (D9222 and D9223), and the therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pay for the dental services. You say that you need the tooth pull and you have high 
anxiety, so you need the sedation. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the surgical extraction, the deep sedation, and the therapeutic parenteral drugs 
are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical 
extraction (D7210) for tooth #30, the deep sedation (D9222 and D9223), and the therapeutic parenteral drugs 
(D9612).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has tried conservative management 
without improvement of symptoms. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has low back pain and decreased left 
lower extremity reflexes and weakness. As these symptoms constitute a red flag and the enrollee cannot 
undergo magnetic resonance imaging (MRI), the request for CT of the lumbar spine should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the lumbar spine.  
 
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 the semi-precision abutments (D6191) and the semi-
precision attachments (D6192) for tooth #20, #22, #27, and #29. 
 
You asked the Plan to pre-approve the dental services. You say that the bottom of your teeth is gone, and you 
need implants to be able to eat. The Plan denied your request. The Plan says the denial of authorization for 
these services 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
semi-precision abutments (D6191) and the semi-precision attachments (D6192) for tooth #20, #22, #27, and 
#29.