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

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth #21 & #26. 
 
You asked the Plan to pre-approve the dental services. You say that these crowns were supposed to be 
completed in 2022, but due to scheduling conflicts they were not able to be completed until 2023. Therefore, 
these items should be covered. 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. This benefit includes the 
requested crown - porcelain/ceramic (D2740) but is limited to two porcelain-fused-to-metal crowns on any two 
teeth per year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered crowns  Tooth #24 and #25 on February 3, 2023. Therefore, these benefits were 
exhausted as of April 6, 2023. Therefore, we decided that the Plan does not have to pre-approve crown - 
porcelain/ceramic (D2740) Tooth #21 & #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an unspecified 
adjunctive procedure (D9999) provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a new device and you had to pay for 
it yourself. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the limited oral evaluation and the unspecified adjunctive procedure 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 limited 
oral evaluation (D0140) and an unspecified adjunctive procedure (D9999) provided on August 15, 2022.
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). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you are trying to prevent 
yourself from needing to be on insulin and it would make financial sense to cover the sensors. 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 for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the supply 
allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7140) for tooth #23, #24, and #25 
provided by an out-of-network provider on October 26, 2022. 
 
You asked the Plan to pay more for the dental services. You say that there were no in-network providers 
available, and you had to use the out-of-network provider and you would like the Plan to pay for the dental 
services. The Plan denied your request. The Plan says 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. 
Therefore, we decided that the Plan does not have to pay more for the extractions (D7140) for tooth #23, #24, 
and #25 provided by an out-of-network provider on October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a PET scan provided on December 19, 
2022. 
 
You asked the Plan to waive the coinsurance for a PET scan. You say that you disagree with the out-of-pocket 
cost share for the procedure. 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 15% 
coinsurance for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay $617.01 coinsurance for a PET scan. The total charged is less than the standard 
amount for a PET scan because your maximum out-of-pocket was met. This item/service falls within the 
Medicare-covered radiological diagnostic 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 
coinsurance for a PET scan provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 99135. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99135 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 provided on April 10, 2022. 
 
You asked the Plan to pay for procedure code 99490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We find that CPT code 99490 billed for date of service April 10, 2022, is not supported in the medical record. Specifically, the medical records provided did not include this date of service. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99490 provided on April 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation - new or established 
patient (D0150), and intraoral - complete series of radiographic images (D0210) provided on December 22, 
2022, and January 9, 2023. We also decided that the Plan does not have to pay for a 3D photographic image 
(D0351), pontic - porcelain fused to high noble metal (D6240), pontic - porcelain/ceramic (D6245) retainer 
crown - porcelain/ceramic (D6740), retainer crown - porcelain fused to high noble metal (D6750), extraction, 
erupted tooth or exposed root  (D7140), extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and bone graft at time of implant 
placement (D6104) provided on December 22, 2022 and January 9, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D0150 and D0210. You say that 
you are requesting reconsideration as you dont understand why the Plan denied the claim for services. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. This includes the dental 
codes represented by D0150 and D0210. The Plan also says the dental codes represented by D0351, D6240, 
D6245, D6740, D6750, D7140, D7210 and D6104 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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation - new or 
established patient (D0150), and intraoral - complete series of radiographic images (D0210) provided on 
December 22, 2022, and January 9, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental codes represented by D0351, 
D6240, D6245, D6740, D6750, D7140, D7210 and D6104 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a 3D photographic image (D0351), pontic - 
porcelain fused to high noble metal (D6240), pontic - porcelain/ceramic (D6245) retainer crown - 
porcelain/ceramic (D6740), retainer crown - porcelain fused to high noble metal (D6750), extraction, erupted 
tooth or exposed root  (D7140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated (D7210), and bone graft at time of implant 
placement (D6104) provided on December 22, 2022 and January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial upper denture (D5213) and a partial lower denture 
(D5214) provided on December 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan was supposed to help you pay the bills 
and some of the services. The Plan denied your request. The Plan says the denial of payment for these services 
is correct, because dentures 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 partial 
upper denture (D5213) and a partial lower denture (D5214) provided on December 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical tape (A4452). 
 
You asked the Plan to pre-approve the surgical tape. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that tape is covered when needed to hold on a wound 
cover, elastic roll gauze or non-elastic roll gauze. Additional tape is not required when a wound cover with an 
adhesive border is used. 
 
We looked at the file and Medicare rules. The Lidocaine patches used by the enrollee are self-adherent. Based 
on this information, we decided that Medicare rules for coverage of the surgical tape have not been met. 
Therefore, we decided that the Plan does not have to pre-approve surgical tape (A4452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you were told the compression 
socks would be covered and you would like to appeal the denied items. The Plan denied your request. The Plan 
says the requested dressing is a non-covered surgical dressing. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs new complete denture - 
maxillary due to it becoming loose. 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. This benefit includes the 
requested complete denture - maxillary (D5110) but is limited to limited to one (1) per arch every five (5) 
years. Removable prosthetics limit each other, and other prosthetics restorations previously made, may limit the 
benefit. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered complete denture - maxillary (D5110) and partial mandibular denture (D5214) on 
April 27, 2021. Therefore, this benefit has been exhausted as of January 17, 2023. Therefore, we decided that 
the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on December 7, 2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you believe you received a routine 
prophylaxis cleaning and not a full mouth debridement on the date in dispute. The Plan denied your request. 
The Plan says D4355 is not included in the list of covered preventive dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a full mouth 
debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided 
on December 7, 2022.  
 
Your complaint about your dissatisfaction with the provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the services approved 
because the last procedure in 2022 did not fit well. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 or services was exhausted on the date of service of May 13, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that your testing with the 
glucometer has become overwhelming and the CGM with help you with being a diabetic. 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 for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99221 provided on January 3, 2022. 
 
You asked the Plan to pay for procedure code 99221. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for procedure code 99221. Specifically, there is no evidence in the case file that the 
column I code, 99223 was billed and paid for on the same date of service at issue. Therefore, we decided that 
the Plan has to pay for procedure code 99221 provided on January 3, 2022.  
 
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.