Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 01, 2022. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on September 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had knee surgery and fell and re-injured your 
knee and need to receive therapy services. The Plan denied your request. The Plan says you do not meet the 
criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that you were told that this would be covered. 
The Plan denied your request. The Plan says this is not a covered continuous glucose monitor. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 9, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 16, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a clinic visit provided on May 17, 2022. 
 You asked the Plan to pay for a clinic visit. You say that you did not have other insurance coverage during this 
time and the Plan should cover the services. 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 a clinic visit provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-ray, cleaning, 
and sales tax (D9985, D0120, D1110, D0274) provided on March 6, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. This benefit does not include sales tax. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-ray, 
cleaning, and sales tax (D9985, D0120, D1110, D0274) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), and pulp vitality tests (D0460) provided on 
March 30, 2023. 
 
You asked the Plan to pay for the consultation and pulp vitality tests. You say that with your new diagnosis, a 
savings of approximately 90% over the cost of a root canal and crown procedure, you feel the Plan should 
cover this claim of only $341.00. The Plan denied your request. The Plan says these services are not covered 
under your dental plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310), and pulp vitality tests (D0460) provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E2301). 
 
You asked the Plan to pre-approve a power standing system. You say that you would like the enrollee to be 
evaluated and approved for the standing frame. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power standing feature (E2301) is non-covered 
because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power standing system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power standing system (E2301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic dental crown (D2740) and the core 
buildup, including any pins when required (D2950) provided on January 30, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these 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 dental items provided are not 
among those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic dental crown (D2740) and 
the core buildup, including any pins when required (D2950) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (D5226). 
 
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 August 27, 2022. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - flexible base 
(D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a retainer crown - full cast noble metal (D6792), 
retainer crown - porcelain fused to noble metal (D6752), and pontic - cast high noble metal (D6210) provided 
on January 31, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D6792, D6752 and D6210. You 
say that you predetermination shows this would pay $3075.00 and you had called to confirm that the bridge 
would pay at 100%. The Plan denied your request. The Plan says your benefit for the requested service s$1,000 
dollar limit was met. 
 
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 services was exhausted on date of service January 31, 2023. Therefore, we decided 
that the Plan does not have to pay more for a retainer crown - full cast noble metal (D6792), retainer crown - 
porcelain fused to noble metal (D6752), and pontic - cast high noble metal (D6210) provided on January 31, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral exam (D0120), bitewing x-rays-four 
radiographic images (D0274), and the dental cleaning (D1110) provided on February 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  
Therefore, we decided that the Plan does not have to pay more for the periodic oral exam (D0120), bitewing  
x-rays-four radiographic images (D0274), and the dental cleaning (D1110) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) and a medical eye 
examination (92012) provided on March 31, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015) and a medical eye examination 
(92012). You say that you are an in-network provider. 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 determination of 
refractive state (92015) and a medical eye examination (92012) provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified restorative procedure, by report (D2999), and 
bone replacement graft for ridge preservation - per site (D7953) provided on December 22, 2022. 
 
You asked the Plan to pay for the unspecified restorative procedure by report and bone replacement graft for 
ridge preservation. You ask to please consider this claim ending in 8352-G as the primary insurance has paid 
for the services rendered for the enrollee. The Plan denied your request. The Plan says these services are not 
included in the enrollee's dental coverage when received. 
 
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 pay for an unspecified 
restorative procedure, by report (D2999), and bone replacement graft for ridge preservation - per site (D7953) 
provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010 x3) provided on March 1, 2023. 
 
You asked the Plan to pay for the surgical placement of implant body: endosteal implant. You say that you 
were informed by the Plan that there was no waiting period so this claim should be reconsidered given that call. 
The Plan denied your request. The Plan says this implant service is not a covered benefit under your plan. 
Charges for any type of implant and all related services, including crowns or the prosthetic device attached to 
it; precision or semi-precision attachments; over-dentures and any endodontic treatment associated with over-
dentures; other customized attachments are excluded from coverage. 
 
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 surgical 
placement of implant body: endosteal implant (D6010 x3) provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions, cone beam computed tomography (CT) Scan, 
immediate maxillary/mandibular partial dentures, radiographic surgical implant index, bone graft, and semi-
precision attachment/abutment placement (D7140 x5, D7210 x8, D0367, D5130, D5140, D6190, D6010 x4, 
D6104 x4, D6191 x4, D6192 x4) provided on September 22, 2022. 
 
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 
extractions, cone beam computed tomography (CT) Scan, immediate maxillary/mandibular partial dentures, 
radiographic surgical implant index, bone graft, and semi-precision attachment/abutment placement (D7140 x5, 
D7210 x8, D0367, D5130, D5140, D6190, D6010 x4, D6104 x4, D6191 x4, D6192 x4) provided on September 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  unspecified preventive procedure (D1999) provided on 
February 8, 2023. 
 
You asked the Plan to pay for  unspecified preventive procedure. You say that this should be covered. 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 pay for  
unspecified preventive procedure (D1999) provided on February 8, 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 16, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was an 
emergency since in the past you had suffered a heart stroke. You also say the provider was called but in about 
another 6 minutes you were able to be revived shortly before the ambulance arrived. 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 16, 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 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete series 
of radiographic images (D0230), and panoramic imaging (D0330), provided on March 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that you would have no financial 
responsibility for these services. 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 November 13, 2019, November 18, 2022, and March 14, 2023. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), a complete series of radiographic images (D0230), and panoramic 
imaging (D0330), provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shipping cost provided on March 3, 2023. 
 You asked the Plan to pay for the shipping cost . You say that the Plan should pay for shipping because where 
you get your glasses from should not matter. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, shipping costs are not listed as a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the shipping cost have not been met. 
Therefore, we decided that the Plan does not have to pay for the shipping cost provided on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic cast (D0470) and the compete upper dentures 
(D5110) provided from April 4, 2022, to April 15, 2022. 
 
You asked the Plan to pay for the diagnostic cast (D0470) and the compete upper dentures (D5110). You say 
that your dentures were first approved, and then denied. The Plan denied your request. The Plan says the 
services are not covered 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 diagnostic cast (D0470) and the 
compete upper dentures (D5110) are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the diagnostic cast (D0470) and the compete upper dentures (D5110) 
provided from April 4, 2022, to April 15, 2022.