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

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this 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. 
 
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 April 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and 
mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthetic for the first 15 minutes (D9222). 
 
You asked the Plan to pre-approve general anesthetic for the first 15 minutes (D9222). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this service is 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 
general anesthetic for the first 15 minutes (D9222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. 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 item 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 dental item was exhausted on date of service February 24, 2022.  
 
  
 
 
 
 
Specially, the Plans contract states that a lower partial denture is covered once every 60 months. You 
previously received this dental item on February 24, 2022, less than 60 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the dental item requested in this case. Therefore, 
we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) of teeth number 3, 6, 11, 14, 
22, and 27. 
 
You asked the Plan to pre-approve implant placement (D6010) of teeth number 3, 6, 11, 14, 22, and 27. You 
say that you are appealing with supporting records. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) of teeth number 3, 6, 11, 14, 22, and 27.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 3, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on April 3, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower extremities. 
 
You asked the Plan to pre-approve the MRI . You say that the services are medically necessary. The Plan 
denied your request. The Plan says that there is no information that would allow them to select the specific 
guideline criteria needed for review that apply to your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the request for a bilateral foot MRI is reasonable 
based upon the history and physical exam. The request 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the lower extremities.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a socket replacement and a new prosthesis to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the socket replacement and the new prosthesis. You say that you would like 
to see the OON provider because you have been working with them for years. The Plan denied your request. 
The Plan says the requested provider is an OON provider and there is already an approved authorization with 
an in-network provider that can provide the same services as the OON provider. 
 
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. Also, we found an approved authorization 
with an in-network provider that provides the items/services at issue. 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 socket replacement and a new prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D0330) for tooth #19 provided 
on April 27, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the document you received said you would 
owe $0 and it was never made clear to you that you had a $500 limit. The Plan denied your request. The Plan 
says your annual dental maximum benefit for the year has already been exhausted. Also, it was verified that 
you were told the proper dental benefits prior to the date of 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, certain limitations apply. The record 
shows the Plan paid $100 for dental services on March 8, 2023. On April 27, 2023, the Plan paid $400 for the 
dental service. For the year of 2023 the Plan paid $500 ($100 paid + $400 paid) for dental services; therefore, 
your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of April 27, 
2023. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D0330) for 
tooth #19 provided on April 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services procedure codes S9129 and S9131 
billed for date of service April 6, 2023 to April 20, 2023. 
 
You asked the Plan to pay for the home health services. You say that you were not informed that you should 
obtain pre-approval for the home health care. The social worker took your home address, contact information 
and were told that you would be receiving home health care for your therapy. The Plan denied your request. 
The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9129 and S9131 has a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code S9129 and S9131 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code S9129 and S9131 have not been met. Therefore, 
we decided that the Plan does not have to pay for home health services procedure codes S9129 and S9131 
billed for date of service April 6, 2023 to April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver, transmitters and sensors. 
 
You asked the Plan to pre-approve the Dexcom G6 received, transmitters and sensors. You say that you weren't 
told that these services were not covered. You also say that the Libre system does not provide stability for you. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands.  The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered 
under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G6 received, transmitters and sensors. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 receiver, transmitters and sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided on April 5, 
2023. 
 
You asked the Plan to pay for the infusion services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 
We looked at the file and Medicare rules. The billed service is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for infusion services (96365, 96366, 96521) provided 
on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete upper denture (D5110) and a complete lower denture 
(D5120). 
 
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 that the enrollee has exhausted the allowable benefit 
for the requested dental items in this case.  
 
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. Specifically, the Plan has stated that the enrollee has exhausted the allowable 
benefit for the requested dental items in this case. However, the plan has not provided relevant contract 
information to show often dentures are covered. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to pre-approve a complete upper denture (D5110) 
and a complete lower denture (D5120).  
 
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 pre-approve therapeutic radiology simulation-aided field setting; 
complex, therapeutic radiology simulation-aided field setting; simple, high dose rate electronic brachytherapy, 
and office visit (77290, 7728, 0394T, 99214). 
 
You asked the Plan to pre-approve electronic brachytherapy and associated services. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 electronic brachytherapy and associated 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no compelling reasons offered for why stereotactic radiotherapy (SRT) would be needed over more standard approaches of radiation delivery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy and associated services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve therapeutic radiology simulation-aided field setting; 
complex, therapeutic radiology simulation-aided field setting; simple, high dose rate electronic brachytherapy, 
and office visit (77290, 7728, 0394T, 99214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment-includes placement 
(D6057) and an abutment supported porcelain fused to metal crown (high noble metal) (D6059). 
 
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 dental 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 custom fabricated abutment-includes 
placement (D6057) and an abutment supported porcelain fused to metal crown (high noble metal) (D6059).
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 the enrollee has a genetic condition and 
disability, and the custom inserts should be approved for the enrollee. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be approved and paid. 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 February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown teeth #22, #27 (D6752), pontic teeth #23, 
#24, #25, and #26 (D6242) and a core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown teeth #22, #27 (D6752), pontic teeth #23, #24, #25, and #26 (D6242) and a core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration 
(D9610). 
 
You asked the Plan to pre-approve therapeutic parenteral drug, single administration. You say that they are 
going to remove your teeth and it will be better if you're asleep. 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 pre-approve 
therapeutic parenteral drug, single administration (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups (D2950 x 4), crowns-porcelain fused to 
predominantly base metal (D2751 x 4), a bone replacement graft-of a retained natural tooth-first site in 
quadrant (D4263), and an upper partial denture (D5213). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested items/services 
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 or services are not 
among those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pre-approve core buildups (D2950 x 4), crowns-porcelain 
fused to predominantly base metal (D2751 x 4), a bone replacement graft-of a retained natural tooth-first site in 
quadrant (D4263), and an upper partial denture (D5213).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drug. There is no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.