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

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) for teeth numbers 
9,10, a custom fabricated abutment (D6057) for tooth number 4 and an abutment supported porcelain/ceramic 
crown for tooth number 4.  
 
You asked the Plan to pre-approve the dental services. You say that the patient is an edentulous, maxillary with 
difficulty to eat on regular meals due to unfinished treatment. 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 with a previous 
preauthorization for a custom fabricated abutment (D6057) for teeth 6, 11 abutment supported retainer (D6068) 
for teeth 6, 11, a porcelain/ceramic (D6245) for teeth 7 and 8, a maxillary partial denture (D5255), and a 
mandibular partial denture (D5226) with approval from June 11, 2023, to September 11, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain/ceramic pontic (D6245) for teeth numbers 9,10, 
a custom fabricated abutment (D6057) for tooth number 4 and an abutment supported porcelain/ceramic crown 
for tooth number 4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on April 4, 2023. 
 
You asked the Plan to pay for D2950. You say that you pay extra for dental insurance. This should be covered. 
The Plan denied your request. The Plan says the denied service is not a covered dental 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 pay for a core 
build-up (D2950) provided on April 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not feeling well and because of your medical condition you called 911. You also say that what happened to you 
that night was beyond your control and you were not aware of the Medicare plan non-transport. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), the panoramic radiographic image (D0330), the 
caries risk assessment and documentation (D0602), a cleaning (D1110), and the application of fluoride 
(D1206) provided by an out-of-network provider on May 18, 2023. You asked the Plan to pay for the dental services. You say that you were advised that the provider was in-
network, so you got the dental services done. The Plan denied your request. The Plan says the comprehensive 
oral evaluation, the intraoral radiographic images, bitewings, the panoramic radiographic image, a cleaning, 
and the application of fluoride were received from an out-of-network provider and are not covered by your 
supplemental benefits. Also, the caries risk assessment and documentation 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. 
 
The record shows you received the comprehensive oral evaluation, the intraoral radiographic images, 
bitewings, the panoramic radiographic image, a cleaning, and the application of fluoride 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. The caries risk 
assessment and documentation are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral radiographic images 
(D0220 and D0230), bitewings (D0274), the panoramic radiographic image (D0330), the caries risk assessment 
and documentation (D0602), a cleaning (D1110), and the application of fluoride (D1206) provided by an out-
of-network provider on May 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 23, 2023. 
 
You asked the Plan to pay for the medication. You say that you received the medications while you were in the 
hospital. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on May 23, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on May 19, 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 February 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) 
provided on May 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that according 
to the Affordable Care Act under 45 Code of Federal Regulations (CFR) this service should be covered as an 
essential health benefit. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 The ambulance company did not provide transport services on February 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 $4,000 annual dental allowance amount was exhausted on date of service January 19, 2023. The 
remaining balance amount of $3,940 is the enrollees responsibility. Therefore, we decided that the Plan does 
not have to pay for dental services provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
March 8, 2023. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you purchased the 
Inogen as it was easy to handle and light in weight. You also say that you are able to move around more and be 
more active doing things that you like to do giving you a better life. The Plan denied your request. The Plan 
says we will cover rental of oxygen equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that Part A/Part B Medicare Administrative 
Contractors may not pay for oxygen equipment that is purchased on or after June 1, 1989.  
 
 
 We looked at the file and Medicare rules. Specifically, the record shows you purchased the oxygen 
concentrator, and Medicare does not pay for purchased oxygen equipment. The Plan only pays for rented 
oxygen equipment. Based on this information, we decided that Medicare rules for coverage of the portable 
oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
the portable oxygen concentrator purchased on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 6, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you went to an in-network dentist for a crown 
and the evaluation was needed to establish as a new patient. 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 the Plan paid for a limited oral evaluation (D0140) on May 24, 2023, and June 20, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of  June 20, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot inserts provided on May 2, 2023. 
 
You asked the Plan to pay for the foot inserts. You say that you went to a chiropractor because it is less 
expensive for the product. The Plan denied your request. The Plan says the requested payment for the services 
is not covered under Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the ordering physician was a chiropractor and the services provided were not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the foot inserts 
provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on April 21, 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 
intraoral x-ray (D0210) provided on April 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice care provided from May 30, 2023, to May 31, 2023. 
 You asked the Plan to pay for the hospice care. You say that you are seeking payment for the hospice care 
provided to the enrollee. 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 hospice care provided from May 30, 2023, to May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the crown. You say that you need to have the crown so you can eat proper 
food. You say you have diabetes and digestive problems so you need to eat proper food. The Plan denied your 
request. The Plan says the service is not eligible for coverage under the medical benefit. The Plan also 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 service is not covered under the medical benefit; however, the Plan offers a dental benefit in excess of 
Medicare coverage. The record shows your benefit for the requested item or service was exhausted on date of 
service August 24, 2021. Therefore, we decided that the Plan does not have to pre-approve a crown-
porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume 
assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this has been tried as 
an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on May 11, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on May 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (A5514, A5500) provided on April 17, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the foot orthotics. 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 were non-
emergent and prior authorization was not obtained. 
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for foot orthotics (A5514, A5500) provided on April 
17, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that you would like for the Plan to consider 
this pre-authorization. The Plan denied your request. The Plan says that although their decision was not timely, 
they would have overturned their decision at the plan level if they had processed the appeal within the required 
timeframe. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers core buildup 
(D2950) when the services are medically necessary and reasonable. 
 
We looked at the file, the Plan rules and Medicare rules. Based on this information, we decided that the Plan's 
rules for coverage of core buildup (D2950) have been met. Therefore, we decided that the Plan has to pre-
approve core buildup (D2950).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on June 7, 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 
extraction (D7140) provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) of the lower 
right and lower left quadrants, the infiltration of sustained release therapeutic drug (D9613) of the lower right 
and lower left quadrants, the infiltration of sustained release therapeutic drug (D7415), a therapeutic parenteral 
drug (D9610) and the application of desensitizing medicament (D9910). 
 
  You asked the Plan to pre-approve the removal of torus mandibularis (D7473) of the lower right and lower left 
quadrants, the infiltration of sustained release therapeutic drug (D9613) of the lower right and lower left 
quadrants, the infiltration of sustained release therapeutic drug (D7415), a therapeutic parenteral drug (D9610) 
and the application of desensitizing medicament (D9910). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your EOC states these are not covered services of 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 
removal of torus mandibularis (D7473) of the lower right and lower left quadrants, the infiltration of sustained 
release therapeutic drug (D9613) of the lower right and lower left quadrants, the infiltration of sustained release 
therapeutic drug (D7415), a therapeutic parenteral drug (D9610) and the application of desensitizing 
medicament (D9910).