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

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954) 
provided on July 19, 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 
prefabricated post and core in addition to crown (D2954) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that you were not completely satisfied with the 
service you received with the Plan hearing vendor. The Plan denied your request. The Plan says benefits do not 
include or cover any hearing aids that are not Plan vendor specific hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are purchased through the Plan vendor hearing.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a child prophylaxis (D1120) provided on February 28, 2023. 
 
You asked the Plan to pay for a child prophylaxis (D1120). You say that you talked with a representative and 
she said to resubmit your bill as it should be covered. The Plan denied your request. The Plan says that this is 
not a covered benefit. 
 
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. The Plan said that the child prophylaxis was not covered. However, the Plan did 
not provide verification that this service was not covered. The EOC states that prophylaxis is covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a child 
prophylaxis (D1120) when the services are medically necessary and reasonable. 
 
We looked at the file, and Medicare rules. The EOC clearly states that prophylaxis is a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of a child prophylaxis (D1120) have been 
met. Therefore, we decided that the Plan has to pay for a child prophylaxis (D1120) provided on February 28, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an immediate upper denture (D5130), an immediate 
lower denture (D5140), extractions (D7210) for tooth #18, #22, #23, and #24, and the alveoloplasty (D7310) 
provided on November 30, 2022, and December 1, 2022 . 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reimburse you 
for your dentures. The Plan denied your request. The Plan says your annual dental maximum 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 $45 for dental services on August 11, 2022. On November 30, 2022, the Plan paid $1,695 
for dental services. On December 1, 2022, the Plan paid $1,260 for dental services. For the year of 2022 the 
Plan paid $3,000 ($45 paid + $1,695 paid + $1,260 paid) for dental services. Therefore, your annual dental 
maximum benefit for the year of 2022 was exhausted on the date of service of December 1, 2022. Therefore, 
we decided that the Plan does not have to pay more for an immediate upper denture (D5130), an immediate 
lower denture (D5140), extractions (D7210) for tooth #18, #22, #23, and #24, and the alveoloplasty (D7310) 
provided on November 30, 2022, and December 1, 2022 .
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that the requested supplies are 
medically necessary for the enrollee. 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. Specifically, the request for authorization from the enrollees 
physician 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 supply allowance for the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the supply allowance for a 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on April 11, 2023. 
 
You asked the Plan to pay 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 your benefit for the dental services 
provided 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 services provided was exhausted on date of service February 27, 2023.   
 
 
Specifically, the Plans contract states that one comprehensive oral evaluation is covered every three calendar 
years. You previously received this service on February 27, 2023, less than three years prior, which was paid 
for by the Plan. Additionally, the Plans contract states that one full mouth or panoramic x-ray is covered every 
five calendar years. You previously received a full mouth x-ray on February 27, 2023, less than five years 
prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for the services 
provided in this case. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and the intraoral-complete series of radiographic images (D0210) provided on April 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on March 28, 
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 November 12, 2019. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on 
March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories 
(E1002, E1012, E2311, E1020, E1028, E2605, E0955). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you do not understand 
why the new power wheelchair has been denied. You also say that you cannot use a manual wheelchair. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
records do not support that you are at high risk for skin breakdown, have a history of pressure ulcer(s), or have 
had skin flap surgery. The records do not document that you perform bladder self-catheterization and are 
unable to transfer independently or that you have increased muscle tone or spasticity to meet criteria for the 
power tilt and/or recline and the multiple power option base. As the wheelchair base does not meet criteria for 
approval, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories (E1002, 
E1012, E2311, E1020, E1028, E2605, E0955).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy visits. You say that you could not get into see an in-
network provider in a reasonable amount of time. 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 visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment (D5862) and a complete 
mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve precision attachment (D5862) and a complete mandibular overdenture 
(D5865). You say that you suffer from extremely mouth and lock jaw. The Plan denied your request. The Plan 
says this service/item is not a covered benefit under Medicare. 
 
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 
precision attachment (D5862) and a complete mandibular overdenture (D5865).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service September 
29, 2022. 
 You asked the Plan to pay for procedure code 84480. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 84481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 84480 
is a column II code to column I code 84481. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 84480 billed for date of service September 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010) for teeth 
4, 5, and 6, a custom fabricated abutment (D6057) for teeth 4, 5, and 6 and an abutment supported porcelain 
fused to metal crown (D6059) for teeth 4, 5, and 6. 
 
You asked the Plan to pre-approve a surgical placement of implant body (D6010) for teeth 4, 5, and 6, a custom 
fabricated abutment (D6057) for teeth 4, 5, and 6 and an abutment supported porcelain fused to metal crown 
(D6059) for teeth 4, 5, and 6. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of implant body (D6010) for teeth 4, 5, and 6, a custom fabricated abutment (D6057) for 
teeth 4, 5, and 6 and an abutment supported porcelain fused to metal crown (D6059) for teeth 4, 5, and 6.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) provided on October 22, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was included in 
the global surgery period for code 92928 which was billed on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for hospital care (99232) provided on October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that your medical condition makes it 
clear that the denial should be overturned. The Plan denied your request. The Plan says you do not meet the 
definition of a dressing and you have no wound currently that is being treated. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant, 
custom fabricated abutment  includes placement and abutment supported porcelain/ceramic crown. 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says this service is not covered under your 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. Surgical placement of implant 
body: endosteal implant, custom fabricated abutment  includes placement and abutment supported 
porcelain/ceramic crown are not covered under the Plans dental benefits. 
 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 
surgical placement of implant body: endosteal implant, custom fabricated abutment  includes placement and 
abutment supported porcelain/ceramic crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction erupted tooth or exposed root tooth 12 
(D7140), mandibular partial denture lower arch (D5214) and complete denture maxillary upper arch (D5110). 
 
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 mandibular partial denture lower arch and complete denture 
maxillary upper arch has already been exhausted. The extraction on tooth #12 was already removed on 
November 29, 2012 
 
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 complete denture maxillary upper arch was exhausted on date of service September 16, 
2021. The mandibular partial denture lower arch was exhausted on date of service April 8, 2022. Therefore, we 
decided that the Plan does not have to pre-approve extraction erupted tooth or exposed root tooth 12 (D7140), 
mandibular partial denture lower arch (D5214) and complete denture maxillary upper arch (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37248 rendered on January 18, 2023. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the operative report supports a more appropriate CPT code for the 
diagnostic angiography of the dialysis circuit with angioplasty of the peripheral dialysis segment (CPT 36902) 
as a fistulogram with angioplasty of the cephalic vein was performed of the left upper extremity arteriovenous 
(AV) fistula. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37248 is "Transluminal balloon angioplasty (except 
dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation 
necessary to perform the angioplasty within the same vein; initial vein." 
 We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
diagnostic angiography of the dialysis circuit with angioplasty of the peripheral dialysis segment. There is a 
more appropriate code to report for the service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 37248 rendered on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root planing and scaling (D4342) and periodontal 
maintenance (D4910). 
 
You asked the Plan to pre-approve root planing and scaling and periodontal maintenance. You say that this 
should be covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve root 
planing and scaling (D4342) and periodontal maintenance (D4910).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy visits x8 to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve massage therapy visits x8. You say that you say that you do not like to drive 
far and not all massage therapists offer the treatment you need. 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 
massage therapy visits x8 to be provided by an OON provider.