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

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 5, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you thought you could have these x-rays once a 
year. 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 June 24, 2022. Therefore, we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 5, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown (D6750 x2) and pontic (D6240 x2) provided 
on June 13, 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 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 June 13, 2023. Therefore, 
we decided that the Plan does not have to pay for retainer crown (D6750 x2) and pontic (D6240 x2) provided 
on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure manual therapy techniques, and 
therapeutic activities provided by a chiropractor on February 15, 2023, to, April 10, 2023. 
 
You asked the Plan to pay for the therapeutic procedure, manual therapy techniques and therapeutic activities. 
You say that you were getting much needed relief from the treatments. The Plan denied your request. The Plan 
says that the only covered chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic procedure, manual therapy techniques, and therapeutic 
activities provided by a chiropractor on February 15, 2023, to, April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the inpatient hospital stay on April 27, 
2023. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to inpatient hospital care.  
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient hospital stay was received on April 27, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for the inpatient hospital stay on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 10, 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 April 18, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to returned to your regular dentist 
because you were unsatisfied with the services provided by the nearby dentist. 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 May 2, 2023. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 31, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that this should be 
covered because in February you were denied coverage at the provider for dental work. You also say that you 
sent in the appeal and it was approved although you had already paid for the procedure. The Plan denied your 
request. The Plan says your benefit for limited oral evaluation - problem focused 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 service was exhausted on date of service February 14, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided 
on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) 
provided on July 6, 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 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 March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral-periapical first radiographic image 
(D0220) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) for tooth #3, #18, #20, and 
#30 and a consultation (D9310) provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were required because of 
a medical condition. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the surgical extractions and the consultation 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 requested surgical extractions and consultation in dispute meets the Medicare definition of dental, since it 
is a service which involved the care and treatment of teeth or structures directly supporting the teeth. The 
surgical extractions and consultation does not fall under any of Medicare exceptions for coverage of non-
routine dental care. 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 the surgical extraction (D7210) for tooth #3, #18, #20, and #30 and a consultation (D9310) provided 
on June 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 7, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are not a hospital provider, and you are not 
required to enroll into Medicare. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the core build-up (D2950) on tooth #10. 
 
You asked the Plan to pre-approve the core build-up (D2950). You say that the enrollee has large fills 
separating at the margins and recurrent decay at tooth #10 and #25. You say that when the tooth is prepped 
there will be less than 50% of natural tooth remaining and a buildup is necessary for crown retention.  The Plan 
denied your request. The Plan says that the core build-up (D2950) is not medically necessary. The Plan says 
there appears to be sufficient tooth structure remaining to support and retain a crown without a core build-up.  
 
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 the core 
build-up (D2950) when the services are medically necessary and reasonable. 
 
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 core build-up (D2950). Our 
reviewer says that the service is medically necessary. Our physician reviewer found there appears to be a large 
defective restoration and active caries in tooth #10. In order to provide adequate support and stability for a 
crown restoration, a core buildup (D2950) is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core build-up (D2950) have been met. Therefore, we decided that the Plan 
has to pre-approve the core build-up (D2950) on tooth #10.  
 
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 a determination of refractive state (92015) provided on April 
17, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you went on to the Plan 
vision site to find an eye doctor for your routine eye examination. You also say that you do not have any 
special vision problems and have no idea why the provider would have scheduled you with a specialist. The 
Plan denied your request. The Plan says your visit was not a routine eye examination. 
 
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 these services when the eye refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that you pay $15 for each Medicare-covered 
examination (diagnosis and treatment for diseases and conditions of the eye). The Plan rules also say that 
Original Medicare does not cover routine eye examinations (eye refractions) for eyeglasses/contacts. The 
record shows this was not a routine eye examination. Based on this information, we decided that the Plan's 
rules for coverage of a determination of refractive state (92015) have not been met. Therefore, we decided that 
the Plan does not have to pay for a determination of refractive state (92015) provided on April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on May 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the debridement. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the debridement provided on May 15, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings (A6539) provided on June 26, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for compression stockings 
has already been exhausted. 
 
Medicare generally does not compression stockings. However, the Plan offers a benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers compression stockings in excess of Medicare coverage, certain limitations apply. The 
record shows your benefit for the requested item(s) was exhausted on date of service June 9, 2023. Therefore, 
we decided that the Plan does not have to pay for compression stockings (A6539) provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 the laboratory services provided on May 23, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220) provided on July 18, 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 (D0220) provided on July 18, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xT 648 gene panel provided on March 14, 2023. 
 
You asked the Plan to pay for the Tempus xT 648 gene panel. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. In this case, the Plan denied payment for the Tempus xT 648 gene panel 
provided on March 14, 2023, due to not showing any coverage through the MolDX program. However, the file 
shows that the laboratory report where the sample was tested was in the provider's North Carolina facility. 
Tempus xT is covered under the DEXTM Diagnostics Exchange Registry when performed in the Tempus Labs 
North Carolina facility. Therefore, we decided that the Plan has to pay for the Tempus xT 648 gene panel 
provided on March 14, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 system and supplies. 
 
You asked the Plan to pre-approve the Dexcom G7 system and supplies. You say that the enrollee has type  
2 diabetes and has been properly trained on how to use the Dexcom G7 CGM.  
 The Plan denied your request. The Plan says the Dexcom G7 is a non-preferred brand and there is no clinical 
documentation to show that the enrollee has met the requirements for coverage of a non-covered CGM and 
non-preferred test strip to adequately support the medical necessity. The Plan also says the nurse at the 
providers office agreed to have the enrollee use the preferred CGM. 
 
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 Dexcom G7 system and supplies. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 system and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (E0770). 
 
You asked the Plan to pre-approve the services. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says the requested item 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 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is requesting functional electrical stimulator to regain function and use of a 
lower limb that has been limited by an upper motor neuron injury, resulting in foot drop. The enrollee is non-
ambulatory with muscle strength in the legs of 2/5. The patient uses hoyer lift for transfers. The patient cannot 
perform ADLs and has home health. The enrollee does not meet the criteria for this device. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a functional electrical stimulator (E0770).