Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre Kit 2 sensor. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre Kit 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Kit 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) x4. 
 
You asked the Plan to pre-approve the dental services. You say that you were told by the provider's office they 
are in-network. The Plan denied your request. The Plan says dental services from an out-of-network provider 
are not covered by your supplemental 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. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implant body: endosteal implant (D6010) x4.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425 and A0427) provided on 
October 3, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the claim, and Medicare rules. The claim shows that external cause code, W01.0XXA, was billed as the principal or first-listed diagnosis code incorrectly. Therefore, we decided that the Plan does 
not have to pay for the ambulance services (A0425 and A0427) provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composites (D2335) for tooth #7 and 
#8 and to pay for the resin-based composite (D2335) for tooth #9 and the periapical radiographic image 
(D0220) provided by an out-of-network provider on October 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the requested services should be filed 
under a medical claim and not a dental claim because of an injury that occurred. 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. Your benefit for the resin-based composite has already 
been exhausted. Also, the denial of payment for the periapical radiographic image is correct because it 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the resin-based composites (D2335) for tooth #7 and #8. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The record shows your benefit for the resin-based 
composite was exhausted on the date of service of October 28, 2022. The periapical radiographic image is not 
covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay more for the 
resin-based composites (D2335) for tooth #7 and #8 and to pay for the resin-based composite (D2335) for tooth 
#9 and the periapical radiographic image (D0220) provided by an out-of-network provider on October 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chronic Care Management (99490) provided April 1, 2022. 
 
You asked the Plan to pay for the Chronic Care Management services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the documentation does not support the 
billed services. 
 
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 99490 is Chronic Care Management services 
 
We find that CPT code 99490 is not supported in the medical record. Specifically, records were not provided to 
show that there was a separate initiating face to face visit. Based on this information, we decided that Medicare 
rules for coverage of the Chronic Care Management services have not been met. Therefore, we decided that the 
Plan does not have to pay for Chronic Care Management (99490) provided April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to crown, indirectly fabricated 
(D2952). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services is needed, due to a 
broken tooth. 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. This benefit includes the 
requested post and core in addition to crown, indirectly fabricated (D2952) but is limited to one per 60 floating 
months. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered core buildup, including any pins when required (D2950) on June 21, 2022. 
Although these are two different services, they fall within the same category in your Evidence of Coverage and 
are subject to the same frequency limitations; therefore, this benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve post and core in addition to crown, indirectly fabricated (D2952).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service August 29, 
2022. 
 You asked the Plan to pay for procedure code 70551. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70551 is bundled into 
payment for code 70553. 
 
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 70551 
is a column II code to column I code 70553. 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 70551 billed for date of service August 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room service provided on 
January 03, 2023. 
 
You asked the Plan to waive the copayment for the emergency room service. You say that you did not see a 
provider while at the emergency room. 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 a $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for the emergency room service. This item/service falls within 
the emergency care 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. However, since the allowed amount is less than the standard copayment, you only owe $72.60. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room service 
provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should have explained what was 
covered because you did not know you had out-of-pocket cost. 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. This benefit includes the 
requested topical application of fluoride varnish (D1206) but is limited to two procedures per plan year. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered topical 
application of fluoride varnish on March 30, 2022, and August 2, 2022. Therefore, this benefit was exhausted 
as of December 6, 2022. Therefore, we decided that the Plan does not have to pay for topical application of 
fluoride varnish (D1206) provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on January 9, 
2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service was billed by an individual provider and not an 
approved facility. Based on this information, we decided that Medicare rules for coverage of the opioid 
treatment services have not been met. Therefore, we decided that the Plan does not have to pay for opioid 
treatment services (G2067) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- complete series of radiographic images (D0210), 
panoramic radiographic image (D0330) and comprehensive oral evaluation (D0150) provided on December 15, 
2022. 
 
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 May 3, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral- complete series of radiographic images (D0210), 
panoramic radiographic image (D0330) and comprehensive oral evaluation (D0150) provided on December 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose monitor (CGM) 
and  supply allowance. 
 
You asked the Plan to pre-approve the CGM and supply allowance. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Continuous Glucose monitor (CGM) and  supply allowance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
(D3950) x2. 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested service to be 
approved because it is part of your treatment plan. 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. Canal preparation and fitting 
of preformed dowel or post (D3950) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D3950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve canal 
preparation and fitting of preformed dowel or post (D3950) x2.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61210 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code 61210. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 61210 is bundled into payment for code 61315. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 61210 is a column II code to column I code 61315. While code 
61210 was billed with modifier -59, the medical records provided do not show that code 61210 billed with the  
-59 modifier is a distinct procedural service. 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 61210 billed for date of 
service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on October 20, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items are not payable in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post removal (D2955) and treatment of root canal 
obstruction; non-surgical access (D3331). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee cannot afford the cost for dental 
services, and you are hoping insurance can help pay for services. The Plan denied your request. The Plan says 
these services are not covered under the enrollee's 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. Post removal (D2955) and 
treatment of root canal obstruction; non-surgical access (D3331) are not covered under the Plans dental 
benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2955 and D3331are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve post 
removal (D2955) and treatment of root canal obstruction; non-surgical access (D3331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the denied dental services should have been 
covered by your 2022 benefits. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 items or services was exhausted on the date of service of August 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the panoramic radiographic image (D0330) provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), deep 
sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 
15-minute increment (D9223) x2. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services because you 
are in pain and have dental anxiety. The Plan denied your request. The Plan says these services are 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. Extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210), deep sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  
each subsequent 15-minute increment (D9223) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7210, D9222 and 
D9223 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general anesthesia  first 15 minutes 
(D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) x2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor and supplies. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor and supplies. You say that you are unable to 
check your glucose at home with a fingerstick and are requesting a CGM. The Plan denied your request. The 
Plan says you do not require insulin three or more times daily. 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 2 sensor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 sensor and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are disputing the denied dental service. 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 the date of service of September 27, 
2021. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on 
December 7, 2022.