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

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on May 30, 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 a dental 
consultation (D9310) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for collagen purchased on July 20, 2023. 
 
You asked the Plan to reimburse for collagen. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  
 
The items you asked the Plan to reimburse for are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to reimburse for collagen purchased on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921), and periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) provided on June 13, 2022. 
 
You asked the Plan to pay for the gingival irrigation  per quadrant  and periodontal scaling and root planing. 
You say that you do not feel you are liable. The Plan denied your request. The Plan says your benefit for the 
requested services $1,00 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service November 15, 2022. The Plan 
has provided evidence of having made payments totaling $1,000 towards the cost of dental services provided in 
2022. Therefore, we decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921), 
and periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on June 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on June 19, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you were unaware an authorization was 
required. 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 
provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs to be on a non-
invasive ventilation system. The Plan denied your request. The Plan says that a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is medically necessary. Our physician reviewer found that the enrollee used 
a trilogy ventilator prior to moving and had good results and compliance. The enrollee also has severe COPD 
and chronic respiratory failure. Therefore, continued therapy with a trilogy ventilator is the best practice. 
 
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 home ventilator system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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 dental services provided on April 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would like this covered since its 
medically necessary. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on April 28, 2023.
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 May 
3, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that your history of 
abnormal magnetic resonance imaging (MRI) of the brain showed thinning of the interior nerve fiber layer. 
You also say you were there for a comprehensive evaluation. The Plan denied your request. The Plan says the 
provider performed these services for the member as a result of a medical diagnosis, not as part of a routine 
examination. The Plan also says that as a result, the service is excluded from coverage. 
 
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 it is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover routine (refractive) eye 
examinations. Medical/diagnostic refractions are not a covered benefit. 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 May 
3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), each additional radiographic image (D0230), and 
prophylaxis - adult (D1110) provided on May 10, 2023. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral - periapical first radiographic image, each 
additional radiographic image, and prophylaxis - adult. You say that when you made your appointment it was 
to have your teeth cleaned. You also say that you asked if the provider still covered your insurance and they 
said yes. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and 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. 
 The record shows you received the requested 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 pay for a periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image 
(D0220), each additional radiographic image (D0230), and prophylaxis - adult (D1110) provided on May 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 10, 2023, to May 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for dental services provided on February 10, 2023, to May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364) provided on May 24, 2023. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you don't agree that 
you were charged $150 for the D0364 service. The Plan denied your request. The Plan says procedures not 
listed in the Patient charge schedule guide are not 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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam CT 
capture and interpretation with limited field of view  less than one whole jaw (D0364) provided on May 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft, nasal, maxillary or malar area (21210) and 
bone graft mandible (21215). 
 
You asked the Plan to pre-approve bone graft, nasal, maxillary or malar area and bone graft mandible. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
procedures 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 bone graft, nasal, maxillary or malar 
area and bone graft mandible. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation provided does not contain record of the type or area of your cancer requiring 
radiation. Radiographs do show multiple carious, broken-down teeth in need of extraction. Documentation by 
your provider ordering the radiation is required as stated in the criteria for coverage. 
 
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 bone graft, nasal, maxillary or malar area and bone graft mandible have not 
been met. Therefore, we decided that the Plan does not have to pre-approve bone graft, nasal, maxillary or 
malar area (21210) and bone graft mandible (21215).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation.  
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you continue to suffer through 
back pain until you are relived from a cortisone injection, which helps you get through the day. The Plan 
denied your request. The Plan says the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the LCD requires two diagnostic blocks of the medial nerve branches with each set producing 80 % pain relief. 
However, there is no documentation of prior diagnostic medial branch blocks or of prior RFA of the medial 
branches. Therefore, the request is not medically reasonable and necessary. 
 
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain fused to metal crown 
(high noble metal) (6059), and implant supported crown - porcelain fused to high noble alloys (D6066). 
 
You asked the Plan to pre-approve the dental services. You say that you initiated the implant service on 
February 20, 2023 with an oral with intensions of having the process completed before you changed insurance 
carriers and going on Medicare. You also say that due to the length of the process and failure of the initial 
implant the process has been delayed. The Plan denied your request. The Plan says the requested services are 
not covered in your dental 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 an 
abutment supported porcelain fused to metal crown (high noble metal) (6059), and implant supported crown - 
porcelain fused to high noble alloys (D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for durable medical equipment (DME) provided 
on November 18, 2022, to April 18, 2023. 
 
You asked the Plan to waive the cost share for DME. You say that you disagree with the cost share. 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 $450 deductible and a $525 deductible which applies to durable 
medical equipment (DME).  
 
The item or service you asked the Plan to waive the cost share for falls within the durable medical equipment 
(DME) benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $450 deductible and a $525 deductible which applies to durable medical equipment (DME). You are being 
asked to pay $34.19 towards your $450 deductible. You are also being asked to pay $32.33 towards your $525 
deductible. The total amount you are being asked to pay is $66.52. This cost sharing is a contractual obligation 
that had not been met at the time DME was received on November 18, 2022, to April 18, 2023. Therefore, we decided that the Plan does not have to waive the cost share for durable medical equipment (DME) provided on 
November 18, 2022, to April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia and implant removal 
services (D9222, D6100, D9223) provided on June 14, 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 deep 
sedation/general anesthesia and implant removal services (D9222, D6100, D9223) provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on February 24, 2023, 
through March 10, 2023, from a provider outside of the United States. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services should be covered. The Plan 
denied your request. The Plan says the benefit limit for worldwide coverage has been exhausted. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care with a $20,000 annual maximum allowance.  
We looked at the file, and Medicare rules. The record shows your benefit for the requested item or service was 
exhausted. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided on 
February 24, 2023, through March 10, 2023, from a provider outside of the United States.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PancraGEN pancreatic test. 
 
You asked the Plan to pre-approve the requested testing. You say that the tumor sample came back as cancer. 
The Plan denied your request. The Plan says the test 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 requested testing. Our physician 
reviewer found that you have cystic lesion in the body/tail of the pancreas with ductal dilatation in the body and 
tail of the gland. The PancraGEN test was ordered at time of biopsy with cyst aspiration. In this case, there was 
a solid mass with biopsy that demonstrated adenocarcinoma. This was definitive and no further test is needed 
to make a decision for surgery. Therefore, the PancraGEN test is not medically necessary.  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 requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a PancraGEN pancreatic test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D7956) and bone 
replacement graft (D7953). 
 
You asked the Plan to pre-approve guided tissue regeneration and bone replacement graft . You say that this 
should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration (D7956) and bone replacement graft (D7953).
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 May 
10, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). 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 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 they are a part of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one non-Medicare covered routine 
vision examination per calendar year including refraction. The eye refraction is only covered when performed 
during a routine vision examination. The Plan rules also says that that eye refractions performed in conjunction 
with Medicare-covered eye examinations are not covered. 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 May 10, 2023.