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

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on March 6, 
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 February 6, 2023. 
Therefore, we decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on 
March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the dental cleaning (D1110) and 
the periodic oral evaluation (D0120) provided on June 22, 2023. 
 
You asked the Plan to issue additional reimbursement for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. 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 issue additional reimbursement for the dental cleaning 
(D1110) and the periodic oral evaluation (D0120) provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2710) for tooth #21, #22, #23, #24, #25, #26, and 
#27 provided on June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services should not be denied and the 
information you received does not support the denial of the dental services. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the specific crown is not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2710) for tooth #21, #22, #23, #24, #25, #26, and #27 provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand the frequency as this is 
the first time you have had this procedure done. You also say that it is your understanding it is only done every 
five years. 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 4, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491and 87591) billed for date 
of service January 31, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87491and 87591) billed for date of service January 
31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home or residence visit (99344) provided on July 19, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health 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 were 
non-emergent and prior authorization was not obtained. 
 
  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 home or residence visit (99344) provided on July 
19, 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 biologic materials to aid in soft and osseous tissue 
regeneration (D4265) provided on March 7, 2023. 
 
You asked the Plan to pay for biologic materials to aid in soft and osseous tissue regeneration. 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 Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for biologic 
materials to aid in soft and osseous tissue regeneration (D4265) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond fixed partial denture (D6930) provided 
on July 26, 2023. 
 
You asked the Plan to pay for re-cement or re-bond fixed partial denture. 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 pay for re-cement 
or re-bond fixed partial denture (D6930) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, panoramic radiographic 
image, cleaning (D0150, D1110, D0330) provided on June 13, 2022, and oral hygiene instructions (D1330) 
provided on June 1, 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 the claim was 
filed untimely. Additionally, coverage for oral hygiene instructions denied correctly as they do not fall within 
your dental benefits. 
 
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 rules also say that 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 that a claim for the dental services was not filed until July 21, 2023 (D0150, D1110, D0330). 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instructions provided 
on June 1, 2023 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for a comprehensive oral evaluation, panoramic radiographic image, cleaning (D0150, D1110, 
D0330) provided on June 13, 2022, and oral hygiene instructions (D1330) provided on June 1, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod insulin delivery system and Pods (A9274). 
 
You asked the Plan to pre-approve an Omnipod insulin delivery system and Pods. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an Omnipod insulin delivery system and Pods have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Omnipod insulin delivery system and Pods (A9274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Helicoll, per sq cm (Q4164) and application of skin 
substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 
surface area (15271). 
 
You asked the Plan to pre-approve Helicoll and application of skin substitute graft. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 Helicoll and application of skin 
substitute graft. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found per policy skin substitute is not indicated for sacral pressure wounds. Furthermore, the wound appears to be healing well with current management using wound 
vac. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Helicoll and application of skin substitute graft have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Helicoll, per sq cm (Q4164) and application of skin 
substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 
surface area (15271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on April 
19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. The Plan denied your request. The Plan 
says that the chiropractic manipulative treatment is available in network. 
 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 chiropractic manipulative treatment provided 
on April 19, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography cerebral perfusion analysis (CTP) 
provided on August 3, 2023. 
 
You asked the Plan to pay for the CTP. You say that the service was billed correctly. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the CTP is covered only when the criteria listed in the 
LCD under the Medicare rules section have been met. 
 
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 pay for the CTP. Our reviewer says that the service 
was not medically necessary. Our physician reviewer found the enrollee presented with slurred speech. They 
had no imaging findings of a stroke. There was no endovascular mechanical thrombectomy. 
 
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 CTP have not been met. Therefore, we decided that the Plan does not have 
to pay for a computed tomography cerebral perfusion analysis (CTP) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230) provided on 
August 15, 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 inhalation 
of nitrous oxide/analgesia (D9230) provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a complete upper 
denture (D5110) provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you chose a dental provider that was in-
network, and your denture broke and you would like the Plan to cover the dental services. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the limited oral evaluation 
and a complete upper denture 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. 
 
  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 limited 
oral evaluation (D0140) and a complete upper denture (D5110) provided on August 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466) for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says that this is not medically necessary for the enrollee.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator.
Our Medical Director states that the enrollee has a medical history that includes chronic respiratory failure with
hypoxemia and hypercapnia due to COPD. The enrollee was admitted to the hospital on May 20, 2023, with
acute-on-chronic respiratory failure. Mechanical ventilation was instituted. Noninvasive mechanical ventilation
was subsequently ordered, with a mode of TTV-VAPS AE. The documentation does not support that the
coverage criteria were met in this case. Medicare rules state that payment policy requirements preclude FSS
payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the
illness treated by the device. This means that products currently classified as HCPCS code E0465 or E0466
when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying
medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement
for any of the conditions described in Medicare rules even though the ventilator equipment may have the
capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or
bi-level CPAP therapy for conditions will be denied as not reasonable and necessary. Our Medical Director
found that the enrollee's condition does not meet Medicare criteria for a home ventilator.

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 have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator (E0466) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) provided on August 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were told the service was denied because it 
was 2 days prior to the 6-month waiting period. 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 the Plan paid for a cone beam (D0380) on February 17, 2023; therefore, your benefit for the requested 
item or service was exhausted on the date of service of February 17, 2023. Therefore, we decided that the Plan 
does not have to pay for a cone beam (D0380) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on August 10, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you have been using the same provider for 
eight years. You also say you were never told that they are no longer in your network. The Plan denied your 
request. The Plan says there is no coverage for hearing aids when received from a provider other than the Plan 
hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you obtain the hearing aids through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5261) provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on July 3, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. The Plan denied your request. The Plan 
says that the chiropractic manipulative treatment is available in network. 
 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 chiropractic manipulative treatment provided 
on July 3, 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 prophylaxis (D1110) provided on September 5, 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 January 23, 2023, and 
May 1, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
September 5, 2023.