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

 
We decided that the Plan does not have to pre-approve more for the resin-based composites (D2335) for tooth 
#8, #9, and #10 to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve more for the dental services. You say that you cannot spread the fillings 
over 3 years, and you have $1,000 worth of dental a year. The Plan denied your request. The Plan says your 
benefit for the requested items or services has already been exhausted and the proper cost share was applied. 
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. 
 
The total amount billed for the resin-based composite (D2335) for tooth #8 was $285 and the total allowed 
amount was $126 leaving a difference of $159 ($285 billed - $126 allowed). The total coinsurance amount was 
$69.30 ($126 allowed x 55% coinsurance). The total liability you are responsible for would be $228.30 ($159 
difference + $69.30 coinsurance). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan approved the resin-based composite (D2335) for tooth #8 on May 19, 2023; therefore, your 
benefit for the requested items or services was exhausted on the date of approval of May 19, 2023. You have 
been asked to pay the difference between the out-of-network providers charges and the Plans payment and the 
coinsurance. 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 pre-approve more for the resin-based composites (D2335) 
for tooth #8, #9, and #10 to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not suspected of having 
AD or FTD let alone both diagnoses. The base requirement of the NCD would not have been satisfied. 
Therefore, this request would not be medically necessary or eligible for coverage. 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strip. 
 
You asked the Plan to pre-approve OneTouch Ultra test strip. You say that the request is medically necessary. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for OneTouch Ultra test strip. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Ultra test strip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollees benefit for the requested item 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 enrollees benefit for the requested item was exhausted on date of service May 19, 2022.  
 
  
 
 
Specifically, the Plans contract states that one lower partial denture is covered every 60 months. The enrollee 
previously received this dental item on May 19, 2022, less than 60 months prior, which was paid for by the 
Plan. Therefore, the enrollee has exhausted the allowable benefit for this dental item. Therefore, we decided 
that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown (D2740), a core 
buildup, including any pins when required (D2950), an upper immediate denture (D5130), a lower partial 
denture (D5226), and the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210 x 3). 
 
You asked the Plan to pre-approve the dental items/services. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items/services are not covered under this benefit when received 
from an out-of-network provider. Additionally, a core buildup, an upper immediate denture, and a lower partial 
denture are not covered under the supplemental dental policy. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain/ceramic dental crown (D2740), a core buildup, including any pins when 
required (D2950), an upper immediate denture (D5130), a lower partial denture (D5226), and the extractions, 
of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that the dentures were not delivered because the 
Plan did not approve them and you need the Plan to pay for them. 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 partial lower denture (D5226) on September 20, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of September 20, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not 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. Specifically, the prior authorization from the enrollees physician 
indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that this CGM would help the enrollee. 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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a toilet rail.  
 
You asked the Plan to pre-approve a shower chair and a toilet rail. You say that the requested items are for 
safety precautions. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered 
because they are not primarily medical in nature.  
 
  While a shower chair and the grab bar may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a 
toilet rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs a denture due to their 
missing teeth. 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 partial lower denture (D5214) in April of 2021; therefore, the enrollees benefit for 
the requested item or service was exhausted in April of 2021. Therefore, we decided that the Plan does not have 
to pre-approve a partial lower denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a True Metrix blood glucose monitor (BGM). 
 
You asked the Plan to pre-approve the BGM. You say that you do not like the OneTouch products, and you 
would like to have the same one you had before. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a BGM. Therefore, we decided that the Plan does not have to pre-approve a True Metrix blood glucose 
monitor (BGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve speech therapy. You say that you do not agree with the denial for speech 
therapy by an OON provider. The Plan denied your request. The Plan says the service can be provided by an 
in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
speech therapy to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a True Metric glucose test strip. 
 
You asked the Plan to pre-approve a True Metric glucose test strip. You say that the enrollee needs these 
diabetic supplies. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a True Metric glucose test strip. Therefore, we decided that the Plan does not have to pre-approve a True 
Metric glucose test strip.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that your doctor provided a good argument in the 
documentation for you needing the inserts. You also say that it would cost the plan more money to give you a 
brace you do not need in conjunction with the inserts when only the inserts are needed. 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 (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need this denture. 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 September 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the chiropractic manipulative 
treatments (98942) provided from October 26, 2022, through December 21, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services were billed as maintenance 
therapy, which is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the chiropractic manipulative treatments provided 
in this case are considered maintenance therapy as billed. Maintenance therapy is not a covered benefit.  
  
Additionally, an office visit provided by a chiropractor is not a covered benefit by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for the office visit (99203) and the chiropractic 
manipulative treatments (98942) provided from October 26, 2022, through December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
(D2751). 
 
You asked the Plan to pre-approve the crown - porcelain fused to predominantly base metal. You say that you 
have an infected tooth due to faulty work by your prior dentist and want to get this fixed as soon as possible. 
The Plan denied your request. The Plan says your benefit for the crown - porcelain fused to predominantly base 
metal 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 crown - porcelain fused to predominantly base metal (D2751) was exhausted on date 
of service October 10, 2022. Therefore, we decided that the Plan does not have to pre-approve a crown - 
porcelain fused to predominantly base metal (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate sedation services and unspecified 
adjunctive procedure (D9243, D9999, D9239) provided on March 24, 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 
intravenous moderate sedation services and unspecified adjunctive procedure (D9243, D9999, D9239) 
provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic foot inserts (A5500, A5512). 
 
You asked the Plan to pre-approve foot orthotics. You say that the services should be covered as you disagree 
with the denial. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve diabetic 
foot inserts (A5500, A5512).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953); a guided tissue regenerationresorbable barrier, per site (D4266), and a fixed partial denture 
sectioning (D9120). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft for ridge preservation-per site (D7953); a guided tissue regenerationresorbable barrier, per 
site (D4266), and a fixed partial denture sectioning (D9120).