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

 
We decided that the Plan does not have to pre-approve cone beam computed tomography (CT) capture and 
interpretation with limited field of view-less than one whole jaw (D0364), cone beam computed tomography 
(CT) capture and interpretation with field of view of one full dental arch-lower (D0365), and cone beam 
computed tomography (CT) capture and interpretation with field of view of one full dental arch-upper, with or 
without cranium (D0366).  
 
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 cone beam 
computed tomography (CT) capture and interpretation with limited field of view-less than one whole jaw 
(D0364), cone beam computed tomography (CT) capture and interpretation with field of view of one full dental 
arch-lower (D0365), and cone beam computed tomography (CT) capture and interpretation with field of view 
of one full dental arch-upper, with or without cranium (D0366).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous surgery (D4261). 
 
You asked the Plan to pre-approve the dental service. You say that you were told that periodontics were 
covered and the procedure is necessary before your next treatment. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because the osseous surgery is not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
osseous surgery (D4261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 3), surgical 
removal of implant body (D6100 x 3), bone replacement graft for ridge preservation (D7953 x 3), general 
anesthesia (D9222), general anesthesia each subsequent 15-minute increment (D9223) and therapeutic 
parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial of your 
providers treatment plan. The Plan denied your request. The Plan says these services are not covered benefits 
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 pre-approve 
guided tissue regeneration (D4266 x 3), surgical removal of implant body (D6100 x 3), bone replacement graft 
for ridge preservation (D7953 x 3), general anesthesia (D9222), general anesthesia each subsequent 15-minute 
increment (D9223) and therapeutic parenteral drug (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown resin-based composite (D2710) for tooth #3 
and #5. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the crown resin-based composite 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 a 
crown resin-based composite (D2710) for tooth #3 and #5.
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 June 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
experienced a medical emergency while driving and the police and ambulance were called. You also say that 
you were treated at the scene and did not desire to be transported to the hospital as your sugar had been 
stabilized. 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 June 7, 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 June 7, 2023.
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 requested CGM is 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 prior 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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on March 13, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you say that at the time services were 
rendered, the member did not have a choice of in-network providers due to being in the facility. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781) and anti-
reflective coating (V2750) provided on May 31, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating 
(V2750). You say that you were told by the Plan that you were eligible for $300 towards frames and lenses. 
The Plan denied your request. The Plan says this service is not covered under your contract. 
 
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 covers standard glasses or contact lenses after cataract surgery. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $0 copayment for one pair of 
Medicare-covered standard glasses or contact lenses after cataract surgery. Lens enhancements or deluxe 
frames are excluded from this benefit. Based on this information, we decided that the Plan's rules for coverage 
of deluxe frames (V2025), progressive lenses (V2781) and anti-reflective coating (V2750) have not been met. 
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses 
(V2781) and anti-reflective coating (V2750) provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nebulizer, with compressor provided on 
June 27, 2023. 
 
You asked the Plan to waive the coinsurance for a nebulizer, with compressor. You say that you were not 
aware that there would be any cost sharing or monthly billing. 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 20% 
coinsurance for in-network durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for a nebulizer, with compressor. This item/service falls within 
the in-network durable medical equipment (DME) and related 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. The total you owe is $2.39 ($11.96 
allowed amount x 20% = $2.39). Therefore, we decided that the Plan does not have to waive the coinsurance 
for a nebulizer, with compressor provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 an office visit provided 
on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9966 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code Q9966. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code Q9966 is bundled into 
payment for code Q9967. 
 
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 Q9966 
is a column II code to column I code Q9967. 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 Q9966 billed for date of service July 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 06, 2022, to July 
07, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you are requesting a reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on July 06, 2022, to July 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), and interim crown - further treatment or completion of diagnosis necessary prior to final impression 
(D2799). 
 
You asked the Plan to pre-approve the core buildup  and interim crown. The Plan denied your request. The Plan 
says these services are not a covered expense under the dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 core 
buildup, including any pins when required (D2950), and interim crown - further treatment or completion of 
diagnosis necessary prior to final impression (D2799).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to discharge to the 
LTACH and has too many medical issues that require daily physician management that cannot be safely 
handled in a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One-Touch brand test strips. 
 
You asked the Plan to pre-approve the One-Touch brand test strips. You say that this item is medically 
necessary. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the test strips. Therefore, we decided that the Plan does not have to pre-approve One-Touch brand test 
strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and contact lens fitting (92071) provided on May 15, 2023, by an out-of-network (OON) provider.

You asked the Plan to pay for the vision services. You say that the services were medically necessary. The Plan denied your request. The Plan says services performed by an out-of-network provider are 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 in this case is not a network provider with the Plan. 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 the office visit (99214) and contact lens fitting (92071) provided on May 15, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971RT) provided on June 1, 2023. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The records and order submitted indicate only the left orthosis 
was needed. There is no indication a right orthosis is necessary. Therefore, we decided that the Plan does not 
have to pay for the ankle foot orthosis (L1971RT) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on June 14, 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 Plan's 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 local 
anesthesia (D9215) provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit system (K0108). 
 
You asked the Plan to pre-approve transit system . You say that please review the attached clinicals for 
authorization and appeal for funding of a K0005 manual wheelchair base and accessories. The Plan denied your 
request. The Plan says the transit system is an option for the wheelchair to be used outside of the home. This is 
a convenience item and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transit system have not been met. Therefore, we decided that the Plan does not have to pre-approve 
transit system (K0108).