Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 13, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit provided on 
March 13, 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) 
and the panoramic radiographic image (D0330) provided on February 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that your new provider does not have access to your 
previous records, so you disagree with the denial. The Plan denied your request. The Plan says your benefit for 
the requested items or services has already been exhausted. Also, it was verified that you or the provider did 
not contact the Plan prior to the date of service to confirm 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, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on November 20, 2019; therefore, your 
benefit for the requested items or services was exhausted on the date of service of November 20, 2019. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) and the panoramic radiographic image (D0330) provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular implant /abutment supported removable 
denture (D6111). 
 
You asked the Plan to pre-approve a mandibular implant /abutment supported removable denture (D6111). You 
say that you feel this is medically necessary based on the deterioration with the current denture you have. The 
Plan denied your request. The Plan says this service is not covered under the benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular implant /abutment supported removable denture (D6111).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oral device/appliance (E0485) provided on January 26, 2023.  
 
You asked the Plan to pay for the oral device/appliance (E0485). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the provider is not 
enrolled in the Medicare program. 
 
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, the Plan has provided no evidence showing that the provider is not 
eligible to bill Medicare. It is the Plan's responsibility to provide all supporting evidence to make the 
determination to deny payment for services. Therefore, we decided that the Plan has to pay for the oral 
device/appliance (E0485) provided on January 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not on medications that cause low blood sugars, and 
we are indeed not told of any low blood sugars. The enrollee is not using insulin. Although the CGM may help 
the enrollee control their blood sugars, the coverage criteria are not met at this time. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the case presentation (D9450) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were having pain in your jaw and the dental 
service was medically necessary. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the case presentation 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 case 
presentation (D9450) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided on April 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 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 pulp 
vitality tests (D0460) provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
March 8, 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 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 March 24, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) 
provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported crown (D6066) provided on May 23, 
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 an 
implant supported crown (D6066) provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
16, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you say that your last x-ray was 
in 2021, 17 months ago. You also say that you do not understand how this claim can be denied. The Plan 
denied your request. The Plan says your benefit for the panoramic radiographic image 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 panoramic radiographic image was exhausted on date of service July 20, 2021. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on December 29, 2022. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement, primary and permanent teeth (D3221) 
provided on March 15, 2023. 
 
You asked the Plan to pay for the pulpal debridement. You say that this service should be covered as part of a 
covered endodontic service. The Plan denied your request. The Plan says there is no coverage for D3221 pulpal 
debridement, primary and permanent teeth. 
 
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 pulpal 
debridement, primary and permanent teeth (D3221) provided on March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
provided on March 24, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan. You say that the cost share 
applied was incorrectly assessed. 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 $285 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $285 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 you owe is $96.94, which is less than the standard copayment of a CT 
scan. Therefore, we decided that the Plan does not have to reduce the copayment for a computed tomography 
(CT) scan provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99212) provided on January 18, 
2023. 
 
You asked the Plan to pay for a specialist office visit (99212). You say that you were not aware at the time the 
services were rendered that you were out-of-network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a specialist office visit 
(99212) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on January 30, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you are appealing the 
denial that you received for $150.00. The Plan denied your request. The Plan says your benefit for the limited 
oral evaluation - problem focused 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 limited oral evaluation - problem focused was exhausted on dates of service January 
3, 2023, and February 21, 2023. The plan previously issued payment for services D0140 provided on January 
3, 2023, claim number ending in 860400, and February 21, 2023, claim number ending in 703000 which is 
within the frequency limits. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation - problem focused (D0140) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tridimensional radiography (D0363) provided on April 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 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 
tridimensional radiography (D0363) provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #3 provided on March 23, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the procedure is part of a crown and should be 
covered by the Plan because 2 crowns per year your coverage states. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the core buildup 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 core 
buildup (D2950) for tooth #3 provided on March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion provided on August 01, 2022, to August 07, 2022. 
 
You asked the Plan to pay for home infusion therapy, implanted pump pain management infusion. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home infusion therapy, 
implanted pump pain management infusion provided on August 01, 2022, to August 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals (S5170). 
 
You asked the Plan to pre-approve home delivered meals (S5170). You say that you will be receiving a total of 
56 meals, however, the contract says you should receive 84 meals. The Plan denied your request. The Plan says 
this benefit is exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that meals may be offered as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, for a temporary duration - typically a four-week 
period - per enrollee per year, provided they are ordered by a physician or practitioner.  
 
 We looked at the file and Medicare rules. Medicare rules say that meals may be offered as a supplemental 
benefit immediately following surgery or an inpatient hospital stay, for a temporary duration - typically a four-
week period - per enrollee per year, provided they are ordered by a physician or practitioner. The record shows 
that meals were delivered for four weeks. The record shows that the program is not based on total meals but on 
a four week period. Based on this information, we decided that Medicare rules for coverage of home delivered 
meals (S5170) have not been met. Therefore, we decided that the Plan does not have to pre-approve home 
delivered meals (S5170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for more of 
this. The Plan denied your request. The Plan says your dental maximum allowance amount of $1,000 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 annual dental allowance amount was exhausted on date of service September 28, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a core buildup, 
including any pins when required (D2950). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested upper partial denture 
has already been exhausted. Additionally, a core buildup is 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, certain limitations apply. The record 
shows your benefit for the requested upper partial denture was exhausted on date of service February 22, 2021.   
 
 
 
Specifically, the Plans contract states that 1 upper and/or 1 lower partial denture is covered every 5 years. You 
previously received an upper partial denture on February 22, 2021, less than five years prior, which was paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental item at this time. 
Additionally, a core buildup is not a covered benefit under the supplemental dental policy. Therefore, we 
decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a core buildup, 
including any pins when required (D2950).