Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment (L0464) provided on May 3, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for the durable 
medical equipment (L0464) provided on May 3, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. You and your family are apparently able to access your port and 
provide hydration. You and your family appear to be providing wound care in between nursing visits. Blood 
draws alone are not considered an indication for home health skilled nursing care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a periodic oral evaluation, an adult prophylaxis, resin-
two surfaces, anterior, and resin-one surface, anterior provided on February 9, 2023.  
 
You asked the Plan to reimburse for a periodic oral evaluation, an adult prophylaxis, resin-two surfaces, 
anterior, and resin-one surface, anterior. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says your claim submission was received more than 120 days after the date of 
service. The Plan also says that submissions must be received within 120 days of the date of service or items 
purchase to be reimbursed. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a periodic 
oral evaluation, an adult prophylaxis, resin-two surfaces, anterior, and resin-one surface, anterior when the 
services are medically necessary and reasonable. However, the reimbursement request must be received within 
120 of the service date. 
 
We looked at the file, Medicare rules and Plan rules. Based on this information, we decided that the Plan's rules 
for coverage of a periodic oral evaluation, an adult prophylaxis, resin-two surfaces, anterior, and resin-one 
surface, anterior have not been met. Therefore, we decided that the Plan does not have to reimburse for a 
periodic oral evaluation, an adult prophylaxis, resin-two surfaces, anterior, and resin-one surface, anterior 
provided on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that while other devices can provide a 
similar mode called AVAPS, they are not equipped with the same pressure and flow ranges or features 
necessary for the enrollee's needs of advanced ventilation. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the patient 
may benefit from a BiPAP with AVAPS during sleep, which has not been tried as an outpatient. Also, 
Medicare does not cover a home ventilator when used at settings that can be provided with a BiPAP. Therefore, 
a home ventilator is 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on June 22, 
2023. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that when your crown fell off, you 
called and made an appointment for the following day to have it re-bonded. You also say that your insurance 
provides $1,000 for treatment in addition to the normal preventive care, x-rays, cleaning, etc. The Plan denied 
your request. The Plan says your benefit for the re-cement or re-bond crown 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 re-cement or re-bond crown was exhausted on date of service April 13, 2023. Therefore, we decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on 
June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hydrophilic contact lenses (V2520) provided on May 25, 
2023.  
You asked the Plan to pay for hydrophilic contact lenses (V2520). You say that you thought that the Plan paid 
for the services every year. You also say you do not have the money to pay the doctor back. The Plan denied 
your request. The Plan says the services are covered benefits, but you have exceeded the limits set in your 
agreement. 
 
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 contact lenses every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover contact lenses every two years. The 
record shows this benefit was exhausted on May 25, 2022. Based on this information, we decided that the 
Plan's rules for coverage of hydrophilic contact lenses (V2520) have not been met. Therefore, we decided that 
the Plan does not have to pay for hydrophilic contact lenses (V2520) provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection performed at an outpatient 
hospital facility provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for an injection performed at an outpatient hospital facility. You 
say that you disagree with the copayment applied because the service was performed at a doctors office and 
not a hospital. 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 $195 
copayment for outpatient hospital services. 
 
You have been asked to pay a $195 copayment for an injection performed at an outpatient hospital facility. 
This item/service falls within the outpatient hospital services 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 an injection performed at an outpatient hospital facility provided on May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supplies and 
accessories provided on January 18, 2023. 
 
You asked the Plan to pay for the CGM and supplies. You say that all information was provided and to please 
reprocess this claim. 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 valid proof 
of delivery which support the medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
submitted also did not include an itemized shipping/billing invoice to indicate the specific supplies delivered. 
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 a continuous glucose monitor (CGM), supplies 
and accessories provided on January 18, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each occupational therapy (PT) visit 
provided on March 27, 2023, to May 05, 2023. 
 
You asked the Plan to reduce the copayment for each occupational therapy (PT) visit. You say that you were 
advised there would only be a $5 copayment. 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each occupational therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services 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. The total copayment you owe for OT services is $150 ($25 per visit x 6 
visits = $150). Therefore, we decided that the Plan does not have to reduce the copayment for each 
occupational therapy (PT) visit provided on March 27, 2023, to May 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on July 6, 2023. 
 
You asked the Plan to pay for the consultation. You say that this provider is in-network but it is listed 
incorrectly in your computer service. You also say that is why you are filing an appeal so that things will be 
covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit. The record shows you received the requested dental service from an out-of-network 
provider. Though the Plan offers a dental benefit in excess of Medicare coverage, specific 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 the consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310) provided on July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81456 is bundled into 
payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (D5750) and a reline 
complete mandibular denture (D5751) provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that a complete realign of your immediate dentures 
must be done and is a part of the procedure to ensure the best results. 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 May 24, 2022. Therefore, 
we decided that the Plan does not have to pay for a reline complete maxillary denture (D5750) and a reline 
complete mandibular denture (D5751) provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - mandibular (D5120), and 
complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete mandibular and maxillary dentures. You say that your current 
dentures do not work properly. You also say that you are experiencing pain and having trouble eating. The Plan 
denied your request. The Plan says your benefit for the complete mandibular and maxillary dentures 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 complete mandibular and maxillary dentures was exhausted on date of service 
September 29, 20219. Therefore, we decided that the Plan does not have to pre-approve the complete denture - 
mandibular (D5120), and complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure, periodontal scaling 
and root planing, and intraoral x-ray (D4999, D0210, D4341) provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the intraoral x-rays has already 
been exhausted. Coverage for the unspecified periodontal procedures denied correctly as it does not fall within 
your dental benefits. Additionally, the cost-sharing for the periodontal scaling and root planing services applied 
correctly based on the services provided. 
 
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 a $115 copayment for periodontal scaling and root planning. This item/service 
falls within the Dental services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for intraoral x-rays was exhausted on date of service April 11, 2023 (D0210). Additionally, 
this benefit does not include unspecified periodontal procedures. Therefore, we decided that the Plan does not 
have to pay for an unspecified periodontal procedure, periodontal scaling and root planing, and intraoral x-ray 
(D4999, D0210, D4341) provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM), 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you need the monitor because you have 
diabetes. You also say that you don't care who it comes from and if they can provide an in-network provider, it 
is fine with you The Plan denied your request. The Plan says this provider is not part of the Plan's preferred 
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a FreeStyle Libre 2 continuous glucose monitor (CGM), and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant (D4263), and gingival flap procedure, including root planing - four or more contiguous teeth or 
tooth bounded spaces per quadrant (D4240). 
 
You asked the Plan to pre-approve the bone replacement graft and gingival flap procedure. You say that you 
need this surgery because your provider said you have pockets in your teeth and one tooth needs a bone graft. 
The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft  retained natural tooth  first site in quadrant (D4263), and gingival flap procedure, 
including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant (D4240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a replacement of a precision attachment and custom 
fabricated abutment (D6057, D5867) provided on January 4, 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  a 
replacement of a precision attachment and custom fabricated abutment (D6057, D5867) provided on January 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided on June 
16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied x-ray because it 
was to determine if you were getting an abscess due to pain. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the intraoral radiographic image is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic image (D0220) provided on June 16, 2023.