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

 
We decided that the Plan does not have to pay for oral evaluation, problem focused (D0160), collection and 
application of autologous blood concentrate product (D7921), and bone replacement graft (D7953) provided on 
June 19, 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 oral 
evaluation, problem focused (D0160), collection and application of autologous blood concentrate product (D7921), and bone replacement graft (D7953) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified implant procedure, by report (D6199) 
provided on July 18, 2023. 
 
You asked the Plan to pay for the unspecified implant procedure, by report. You say that you have dental 
coverage with your insurance for $4500. You also say that you should not be charged because you still have 
some money left. The Plan denied your request. The Plan says this procedure is not covered under your dental 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
implant procedure, by report (D6199) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) for tooth #9 and a retainer crown (D6740) 
for tooth #7, #8, and #10 provided by on April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that your coverage includes restoration services 
which includes crowns, so you do not understand why the Plan is denying coverage. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because bridges 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 pontic 
(D6245) for tooth #9 and a retainer crown (D6740) for tooth #7, #8, and #10 provided by on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on August 4, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were unaware of the frequency limit and you 
needed new x-rays with your new provider. 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 the intraoral complete series of radiographic images (D0210) on October 26, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of October 26, 
2022. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic 
radiographic image (D0330) provided by an out-of-network provider on April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you said that the Plan told you that the provider 
was an in-network provider. 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. Also, it was verified prior 
to the date of service you were given the correct information about your benefits and providers. 
 
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 (D0150) and a panoramic radiographic image (D0330) provided by 
an out-of-network provider on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on June 26, 
2023. 
 
You asked the Plan to pay for mandibular partial denture. 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 
mandibular partial denture (D5214) provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement calf pads, a flex seating system, and 
joystick controller. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested flex seating system does not serve a purpose that is primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The requested replacement calf pads are already included in the approved power wheelchair. The approved calf 
pads serve the same purpose as the requested replacement pads. 
 
The rules say that codes E2310 and E2311 describe the electronic components that allow the beneficiary to 
control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or 
non-proportional interface). 
 
The joystick at issue was incorrectly requested with code K0108. Codes E2310 and E2311 represent this item. 
The joystick cannot be approved as requested. 
 
Therefore, we decided that the Plan does not have to pre-approve replacement calf pads, a flex seating system, 
and joystick controller.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on June 21, 2023.  
You asked the Plan to pay for an eye refraction (92015). You say that this should be covered because Medicare 
has covered this service every year. You also say it is strange that the Plan only covers part of the examination. 
The Plan denied your request. The Plan says the routine refractive examination is not allowed to this case due 
to the medical conditions billed to the plan 
 
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 it is part of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only covered when part of 
a routine examination. The record shows this was a medical examination. Based on this information, we 
decided that the Plan's rules for coverage of an eye refraction (92015) have not been met. Therefore, we 
decided that the Plan does not have to pay for an eye refraction (92015) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 15, 2023. 
 
You asked the Plan to pay for hearing aids. You say that before you were fitting for hearing aids, you called the 
Plan to find out about reimbursement procedure. You also say at this point you should have been told that the 
rendering provider was out-of-network and offered a list of network providers. The Plan denied your request. 
The Plan says the provider is not part of the vendor network. 
 
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 from a Plan hearing network vendor.  
 
 
  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 pay for 
hearing aids provided on July 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 9, 2023, and billed with codes 87798 and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 9, 2023, and billed with codes 87798 and 87481.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that 10 additional physical therapy visits are 
medically necessary. The Plan denied your request. The Plan says 10 additional physical therapy visits are not 
reasonable and necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had 20 sessions of physical therapy and is currently 
performing dynamic stretching and strengthening exercises. Her motor strength and range of motion are nearly 
normal, and the services of a skilled therapist are not needed for dynamic stretching or strengthening exercises 
and returning to athletic activities. She can continue with a home exercise program. Therefore, the 10 visits of 
additional physical therapy are not medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), lenses 
(V2782), photochromatic tint (V2744), and anti-reflective coating (V2750) provided on May 20, 2023. 
 
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), lenses (V2782), photochromatic 
tint (V2744), and anti-reflective coating (V2750). You say that contacts being covered but the eye examination 
and glasses not being covered does not make any sense. The Plan denied your request. The Plan says you were 
not eligible for benefits on this date of service. 
 
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 no other eyewear has been purchased or provided. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every year or contact lenses. The record shows this benefit was exhausted with the contact lenses 
purchase on May 19, 2023. Based on this information, we decided that the Plan's rules for coverage of frames 
(V2020), progressive lenses (V2781), lenses (V2782), photochromatic tint (V2744), and anti-reflective coating 
(V2750) have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), 
progressive lenses (V2781), lenses (V2782), photochromatic tint (V2744), and anti-reflective coating (V2750) 
provided on May 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a footplate/bracket assembly (K0108), electronic 
connection (E2311), harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve a footplate/bracket assembly, electronic connection, harness, and 
expandable controller. You say that the patient does meet all criteria listed on the denial. The Plan denied your 
request. The Plan says the requested foot plate/bracket assembly coded as K0108 is miscoded. The Plan also 
says that although there are three requested power options (tilt, recline and elevating leg rests), there is not a 
medical need to control these power options through the joystick. 
 
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 a footplate/bracket assembly, electronic 
connection, harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
does not reveal that the patient is unable to control any power options with their own switches given the normal 
upper extremity strength and functional ability (set up for feeding). The documentation does not reveal that the 
patient needs a specialized steering device such as a head switch. Our reviewer found that the correct codes for 
footplates are K0040, K0041 or K0042. Our physician reviewer also found that the request for the footplates as 
K0108 does not meet Medicare guidelines and this is not the correct code for footplates. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a footplate/bracket assembly, electronic connection, harness, and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
footplate/bracket assembly (K0108), electronic connection (E2311), harness (E2313), and expandable 
controller (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - two radiographic images (D0272) provided 
on July 12, 2023. 
 
You asked the Plan to pay for the bitewings - two radiographic images. You say that you were not advised that 
bitewings were only covered one time in a six-month period. The Plan denied your request. The Plan says your 
benefit for the requested bitewing 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 services was exhausted on date of service July 12, 2023.  Therefore, we decided that the Plan does not have to pay for the bitewings - two radiographic images (D0272) 
provided on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the intraoral  comprehensive series of radiographic images 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 service was exhausted on date of service March 25, 2021. 
Therefore, we decided that the Plan does not have to pay for the intraoral  comprehensive series of 
radiographic images (D0210) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5212 and D5211). 
 
You asked the Plan to pre-approve the dental services (D5212 and D5211). You say that you would like to 
request reconsideration of the denied dental services and that the services requested are medically necessary. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve the dental 
services (D5212 and D5211).
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 April 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
received minor care at home by the emergency medical services and started to feel better so there was no need 
to go to the emergency room. You also say that you believe the insurance should cover the non-transport 
ambulance service. 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 April 15, 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 April 15, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a liver biopsy (76942, 47000) with tertiary provider. 
 
You asked the Plan to pre-approve a liver biopsy with tertiary provider. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that your notes do not show that you need tertiary level 
care. 
 
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 a liver biopsy with tertiary provider. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the etiology of the liver mass is unclear and not able to be performed 
locally due to its hypervascularity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a liver biopsy with tertiary provider have been met. Therefore, we decided that 
the Plan has to pre-approve a liver biopsy (76942, 47000) with tertiary provider.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 6, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 6, 2023, by 
an OON provider.