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

 
We decided that the Plan does not have to pre-approve additional extractions, of an erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140 x 5). 
 
You asked the Plan to pre-approve these dental services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 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 services has already been exhausted.  
 
Specifically, the Plans contract states that one tooth extraction is covered per year. The Plan previously 
authorized one tooth extraction on August 8, 2023. Therefore, you have exhausted the allowable benefit for the 
requested services in this case. Therefore, we decided that the Plan does not have to pre-approve additional 
extractions, of an erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x 5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4197, B4220, B4224) provided on 
April 17, 2023 to April 21, 2023. 
 
You asked the Plan to pay for the nutritional supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. No itemized 
shipping invoice was provided. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for nutritional 
supplies (B4197, B4220, B4224) provided on April 17, 2023 to April 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
21, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are appealing the denied claim. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided on May 16, 
2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 provided 
on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
image (D0220), and a cone beam (D0364) provided on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that to keep your teeth healthy the dental office is 
requesting a cleaning every 3 months plus x-rays. The Plan denied your request. The Plan says your benefit for 
the limited oral evaluation and the intraoral radiographic image has already been exhausted. Also, the cone 
beam 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, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) on 
March 7, 2023, and March 9, 2023; therefore, your benefit for the limited oral evaluation and the intraoral 
radiographic image was exhausted on the date of service of March 9, 2023. The cone beam is not covered 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140), the intraoral radiographic image (D0220), and a cone beam (D0364) provided on May 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered were medically necessary. 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 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on May 
16, 2023. 
 
You asked the Plan to pay for non-covered ambulance mileage (A0888). You say that you are requesting 
reconsideration for services rendered by this provider. The Plan denied your request. The Plan says The Plan 
does not have to pay for non-covered ambulance mileage (A0888). 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-covered ambulance mileage (A0888) have not been met. Therefore, we decided that the Plan 
does not have to pay for non-covered ambulance mileage (A0888) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TIPS procedure. 
 
You asked the Plan to pre-approve the TIPS procedure. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request 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 TIPS procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the TIPS procedure is considered experimental/investigational and is not medically 
necessary for the treatment of chronic back pain. 
 
 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 TIPS procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the TIPS procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 provided on March 23, 2023. 
 
You asked the Plan to pay for procedure code G0453. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0453 is not supported in the medical record. Specifically, this service is included in 
code 95870 that was also billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0453 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0453 provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the services requested 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 pay for the dental 
services on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom implant abutment (D6057) and implant supported 
crown (D6058) provided on June 20, 2023. 
 
You asked the Plan to pay for custom implant abutment and implant supported crown. 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 custom 
implant abutment (D6057) and implant supported crown (D6058) provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided at an outpatient 
hospital provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for an injection provided at an outpatient hospital. You say that 
you were told to go down the hall to receive the injections and now you are being charged a copayment that 
you do not agree with. 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 $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for an injection provided at an outpatient hospital. This 
item/service falls within the outpatient surgery 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. The total you owe is $261.11, which is less than the copayment 
applied for an injection provided at an outpatient hospital visit. Therefore, we decided that the Plan does not 
have to waive the copayment for an injection provided at an outpatient hospital provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT imaging of bilateral jaw (D0383), 
collection and application of blood concentrate product (D7291), bone replacement graft (D7953), panoramic 
radiograph (D0330), and cone beam CT image capture with field view of one full dental arch, mandible 
(D0381). 
 
You asked the Plan to pre-approve these dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 cone beam CT imaging of bilateral jaw (D0383), collection and application of blood concentrate product (D7291), 
bone replacement graft (D7953), panoramic radiograph (D0330), and cone beam CT image capture with field 
view of one full dental arch, mandible (D0381).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 22, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records attached support the services 
provided. 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 February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on November 15, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you called the Plan and asked where to go to get the 
hearing aids, and that is where you went to get them. You also say you should not be penalized because you did 
what the Plan told you to do. The Plan denied your request. The Plan says the service was not provided by Plan 
network providers. 
 
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 the enrollee contacts the Plan hearing vender to access the routine hearing examination 
and supplemental hearing aid benefits.  
 
 
  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 have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan gave you incorrect information. 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 by an out-of-network provider on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone and a take home 
supply of methadone; up to 7 additional day supply provided on March 27, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone and a take home supply of methadone; 
up to 7 additional day supply. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for medication assisted treatment, methadone and a take home 
supply of methadone; up to 7 additional day supply provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on May 17, 2023. 
 
You asked the Plan to pay for D2740. You say that you had a cavity under your crown that needed to be taken 
care of. The Plan denied your request. The Plan says D2740 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. You are not enrolled in comprehensive dental benefits. Therefore, we 
decided that the Plan does not have to pay for a dental crown (D2740) provided on May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3480), (L3310), and (L3000). 
 
You asked the Plan to pre-approve the foot orthotics. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3480), (L3310), 
and (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why this is not being 
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 11, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral imaging (D0210) provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you needed these compression 
stockings for blood flow in your legs. The Plan denied your request. The Plan says the compression stockings 
have been correctly denied. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on August 26, 2022, to 
August 27, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on August 26, 2022, to August 27, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) provided on January 12, 
2023. 
 
You asked the Plan to pay for D2332. You say that you do not understand why your husband had this covered 
and you are having it denied. The Plan denied your request. The Plan says the rendered 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 pay for a resin-
based composite (D2332) provided on January 12, 2023.