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

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth-completely bony 
(D7240), the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), a 
bone replacement graft for ridge preservation-per site (D7953), and guided tissue regeneration-resorbable 
barrier, per site (D4266).  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal 
of an impacted tooth-completely bony (D7240), the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), a bone replacement graft for ridge preservation-per site (D7953), and 
guided tissue regeneration-resorbable barrier, per site (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site  
(D7953), and guided tissue regeneration, natural teeth  resorbable barrier, per site  (D4266). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation and guided tissue 
regeneration. You say that you are in pain. You also say that this service is medically necessary because you 
have a lot of bone loss and without the services you will lose the tooth next to the extracted tooth. The Plan 
denied your request. The Plan says any procedures not specifically listed as a covered benefit in this Plan's 
Schedule of Benefits are available at 100% of the usual and customary fees of the treating Plan's selected 
general or specialty care dentist. 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 for ridge preservation - per site  (D7953), and guided tissue regeneration, natural teeth  
resorbable barrier, per site  (D4266).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network duplex scan of the veins 
provided on January 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network duplex scan of the veins. You say that you had to 
go to a different hospital to have this test done and were unaware you had a 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 You have been asked to pay the allowed amount of $128.77 which is less than the $150 copayment for the 
duplex scan. 
 
You have been asked to pay a $128.77 copayment for an in-network duplex scan of the veins. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 in-network duplex scan of the veins provided on January 19, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy services by an OON provider. You say that you do not 
have an in-network provider in your area. The Plan denied your request. The Plan says the service can be 
provided by an in-network 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. 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 
physical therapy services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on February 2, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the 
medical necessity of the inpatient services in dispute.  The Plan denied your request. The Plan says that the 
inpatient hospital care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department on February 1, 2023, with right foot pain 
and swelling. She had dropped her walker on her foot 1 week prior. An x-ray was negative for fracture. She 
was evaluated and started on intravenous (IV) Vancomycin for treatment of possible cellulitis. She was 
admitted and was evaluated by physical therapy. Her condition stabilized and improved, and she was 
considered stable for discharge on February 3, 2023. At the time of inpatient admission, the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on February 2, 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 diabetic shoes (A5500 x 2) and inserts (A5512 x 2) to 
be rendered by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items.  
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes 
(A5500 x 2) and inserts (A5512 x 2) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of a tooth with a 
rubber dam for teeth# 22, 27 (D3910 x 2) and canal preparation and fitting of preformed dowel or post for 
teeth# 22, 27 (D3950 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical 
procedure for isolation of a tooth with a rubber dam for teeth# 22, 27 (D3910 x 2) and canal preparation and 
fitting of preformed dowel or post for teeth# 22, 27 (D3950 x 2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the of the left knee without contrast 
material. 
 
You asked the Plan to pre-approve a CT scan of the left knee. You say that the CT scan is necessary for the 
enrollee. The Plan denied your request. The Plan says the requested CT scan of your left knee is not appropriate 
at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the lower extremity. Our 
physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting for which the CT is being requested. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested CT of the lower extremity without contrast material for the left knee, in this case, is 
not medically reasonable or 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 CT scan of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the left knee without contrast material.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) for tooth #27. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says your annual dental benefit for the year has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $136 for dental services on April 19, 2023. On April 27, 2023, the Plan approved $1,364 
for dental services. For the year of 2023 the Plan has paid and approved $1,500 ($136 paid + $1,364 approved) 
for dental services; therefore, your annual dental benefit for the year of 2023 was exhausted on the date of 
authorization of April 27, 2023. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft (D7953) for tooth #27.
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. 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 when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The prior authorization form indicates that the enrollee does not use 
insulin or have a history of problematic hypoglycemia. 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 pre-approve a dentist appointment and a partial denture to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need a partial denture and you been 
going to the same dentist for 30 years. The Plan denied your request. The Plan says dental services from an out-
of-network provider are not covered by your supplemental benefits. Also, there are multiple in-network 
providers available in your service area.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a dentist 
appointment and a partial denture to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3310 and D3320) for tooth 
#8, #10, and #21. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary because you are in pain. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the endodontic therapy 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endodontic therapy (D3310 and D3320) for tooth #8, #10, and #21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that a Freestyle Libre 3 is medically necessary. 
The Plan denied your request. The Plan says a Freestyle Libre 3 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a body powered finger prosthesis (L7499). 
 
You asked the Plan to pre-approve a body powered finger prosthesis. You say that the Naked Finger 
MCPDriver is the only body powered, functional prosthesis available for the type of amputation the enrollee 
has. You also say that the enrollee is unable to perform many activities of daily living functions effectively.  
The Plan denied your request. The Plan says the criteria for coverage 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 a body powered finger prosthesis. Our 
reviewer says that the requested a body powered finger prosthesis is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested prosthesis is not medically necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.  The documentation does not support the need for the requested prosthesis which exceeds the enrollee's medical and 
functional needs such as a conductive tip option for touchscreen use. The requested prosthesis has features such 
as twelve unique color choices to meet style preferences which also exceeds the enrollee's functional needs. 
Furthermore, the literature does not reveal sufficient large scare long term evidence of clinical effectiveness of 
the use of the requested Naked Finger MCPDriver.   
 
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 body powered finger prosthesis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a body powered finger prosthesis (L7499).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate denture - maxillary (D5130) immediate 
denture - mandibular (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you previously received do 
not fit properly and you are unable to eat, so you would like to be able to have new ones made. 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 immediate denture - maxillary (D5130) immediate denture - mandibular (D5140) but is limited to 
complete dentures (upper and lower) or partial dentures (upper and lower) one upper complete/partial and/or 
one lower complete/partial denture every five calendar years, including routine post-delivery care, includes 
necessary extractions to fit dentures (unlimited). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered immediate denture - maxillary (D5130) and immediate denture - mandibular 
(D5140) on July 12, 2022. Therefore, these benefits have been exhausted as of July 12, 2022. Therefore, we 
decided that the Plan does not have to pre-approve immediate denture - maxillary (D5130) immediate denture - 
mandibular (D5140).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were told 
this service was preventative and would have no 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 $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $129.06, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial overdenture (D5864). 
 
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 the requested dental item 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, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper partial 
overdenture (D5864).