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

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia, 
panoramic radiographic image, intraoral x-rays (D0330, D9239, D0220, D9243) provided on February 6, 2023, 
to July 5, 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 panoramic x-ray has already 
been exhausted. Coverage for the intravenous moderate (conscious) sedation/analgesia denied correctly as they 
do not fall within your benefits. Moreover, 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. 
 
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 (D0330).  
Coverage for the intravenous moderate (conscious) sedation/analgesia denied correctly as they do not fall 
within your benefits. Therefore, we decided that the Plan does not have to pay for intravenous moderate 
(conscious) sedation/analgesia, panoramic radiographic image, intraoral x-rays (D0330, D9239, D0220, 
D9243) provided on February 6, 2023, to July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), frames (V2020) and 
progressive lenses (V2781) provided on July 13, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), frames (V2020) and progressive lenses (V2781). 
You say that you believe you should receive $115 back for glasses that you were told you would receive. The 
Plan denied your request. The Plan says this benefit has been exhausted on this date of service. 
 
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 $100 toward the purchase and fitting of eyeglasses and pair of lenses (one per 
calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $100 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses (one per calendar year). The record shows this benefit has been 
exhausted with this date of service. Based on this information, we decided that the Plan's rules for coverage of 
anti-reflective coating (V2750), frames (V2020) and progressive lenses (V2781) have not been met. Therefore, 
we decided that the Plan does not have to pay for anti-reflective coating (V2750), frames (V2020) and 
progressive lenses (V2781) provided on July 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty or kyphoplasty is 
covered in patients with both of the indicated criteria.   
 
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 this service. Our reviewer says that the 
enrollee does not meet the criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee was being treated for radiculopathy of the lumbosacral region. He presented with low back pain. The 
pain is chronic with a flare that began two months ago. The pain is very limiting. He had a magnetic resonance 
imaging study of the lumbar spine on September 8, 2023. The exam reveals lumbar midline tenderness to 
palpation and percussion. 
 
However, detailed documentation is not evident regarding the L1 compression fracture being acute or subacute 
as the provided magnetic resonance imaging study was from September 8, 2023 (and the fracture was subacute 
at that time). Additionally, there is no documentation of worsening of pain, a progression of the body height 
loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. 
Moreover, there is magnetic resonance imaging corroboration of other plausible causes of pain. Therefore, the 
enrollee does not meet the criteria for coverage of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous vertebral augmentation (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown re-cementation (D2920) provided on August 4, 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 July 27, 2023. Therefore, 
we decided that the Plan does not have to pay for crown re-cementation (D2920) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 14 (D2740) 
and a core buildup, including any pins when required for tooth number 14 (D2950). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items 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 items are not among 
those covered under this benefit.  
  
 
 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 
14 (D2740) and a core buildup, including any pins when required for tooth number 14 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 an office visit provided 
on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 an office visit provided 
on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on January 13, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you had a full year to identify the wrong Plan was 
billed and to resubmit a claim to the correct insurer; however, this did not occur until over a year and six 
months later. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient hospital care was not filed until July 12, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes with no facet joint 
degenerative disease or stenosis. The cause of pain is not clear.   
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on July 05, 2023. 
 
You asked the Plan to pay for annual wellness visit. You say that you are requesting reconsideration for 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 annual wellness visit 
provided on July 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device 
(22869, 22870). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interspinous devices are experimental, more research is needed. 
 
  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950). 
 
You asked the Plan to pay for D2740 and D2950. You say that this dental work is medically necessary. The 
Plan denied your request. The Plan says the requested services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of D2740 and D2950 have been met. 
Dental x-rays were not provided to verify medical necessity. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core build-up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from a CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been 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. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on June 28, 2023. 
 
You asked the Plan to pay for the core buildup. You say that your crown cracked and new crown was needed to 
be installed. You also say that the core build up was necessary to place crown. The Plan denied your request. 
The Plan says this service is not a covered expense 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new doctor visit, the vision test, and the field of vison 
exam provided on March 31, 2023.  
 
You asked the Plan to pay for the new doctor visit, the vision test, and the field of vison exam. You say that the 
provider said they were in-network. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the new doctor visit, the vision test, and the field 
of vison exam have not been met. Therefore, we decided that the Plan does not have to pay for the new doctor 
visit, the vision test, and the field of vison exam provided on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A9278), 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  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) (A9278),
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0367). 
 
You asked the Plan to pre-approve D0367. You say that you would like the Plan to approve this dental work. 
The Plan denied your request. The Plan says the denied dental services are not covered 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 pre-approve a 
cone beam CT capture (D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve D9944. You say that you need this night guard. The Plan denied your 
request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the 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 July 14, 2022. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture (D5226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the level of care needed. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
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 the record indicates that the enrollee has ongoing medical issues and still requires 
acute care services. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 long term acute care hospital (LTACH) services.