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

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that if you do not approve the requested 
service, it will affect your ability to eat properly, and you are having mental stress. 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. This benefit includes the 
requested mandibular partial denture - cast metal framework with resin denture bases (including retentive/ 
clasping materials, rests and teeth) (D5214) but is limited to one per 60 floating months (once every 5 years). 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5214 on July 13, 2021. Therefore, this benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (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 a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not you are being 
treated with insulin. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor (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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you do not agree with the denial of 
the compression stockings. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the need of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that the previous denture hurts your mouth, and 
you need a new 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 the date of service of November 22, 
2022. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient. 

We find that CPT code 99309 is not supported in the medical record. Specifically, the records do not include 
evaluation and management services for the date at issue. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99309 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility mental health visit provided on 
September 27, 2022. 
 
You asked the Plan to pay for a skilled nursing facility mental health visit. You say that this was medically 
necessary and should be covered. 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 a skilled nursing facility 
mental health visit provided on September 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 22 or more classes (G0483) provided on 
September 15, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 22 or more classes. You say that this claim should 
be paid The Plan denied your request. The Plan says that this claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0483 is definitive drug testing of 22 or more classes.  
 
We find that CPT code G0483 is supported in the medical record. Specifically we reviewed the claim and 
found that 22 or more classes of drugs were tested and billed correctly. Based on this information, we decided 
that Medicare rules for coverage of the definitive drug testing of 22 or more classes have been met. Therefore, 
we decided that the Plan has to pay for the definitive drug testing of 22 or more classes (G0483) provided on 
September 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary upper denture (D5820) and a temporary 
lower denture (D5821). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dentures are medically 
necessary to help you chew and if not approved it can affect your speech. The Plan denied your request. The 
Plan says the denial of authorization for these services is correct, because the temporary upper and lower 
dentures 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 pre-approve a 
temporary upper denture (D5820) and a temporary lower denture (D5821).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD) 
procedure to L3-L4, represented by CPT code(s) 0275T. 
 
You asked the Plan to pre-approve MILD procedure. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you do not meet criteria for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar decompression is only covered for 
enrollees who are enrolled in a clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that you are enrolled in a clinical 
study. Based on this information, we decided that Medicare rules for coverage of MILD procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive lumbar 
decompression (MILD) procedure to L3-L4, represented by CPT code(s) 0275T.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle libre 2 sensor KIT. 
 
You asked the Plan to pre-approve Freestyle libre 2 sensor KIT. You say that you really need the request to be 
approved because you have a hard time checking your blood sugar. The Plan denied your request. The Plan 
says you do not meet Medicare criteria. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of 
Freestyle libre 2 sensor KIT have not been met. Therefore, we decided that the Plan does not have to pre-
approve Freestyle libre 2 sensor KIT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pre-approve the crown - porcelain. You say that it is painful for you to eat food. The 
Plan denied your request. The Plan says it is not medically necessary to replace the cap on your tooth. The x-
rays of your tooth do not show that you have a cavity under the old cap. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown - 
porcelain when the services are medically necessary and reasonable.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown - porcelain. Our reviewer 
says that the request for a crown on tooth #4 is not medically necessary. Our physician reviewer found the 
documentation indicates the presence of a crown on tooth #4. There is no evidence of recurrent caries 
radiographically and there was no narrative indicating why a replacement crown was necessary. The crown that 
is in place appears adequate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown - porcelain fused to high noble metal (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2740) provided on May 26, 2022. 
 
You asked the Plan to pre-approve 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 were 
non-emergent and prior authorization was not obtained. 
 
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 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 pre-approve a dental 
crown (D2740) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic, retainer crown and extraction (D6740, D7210, 
D6245) provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic, 
retainer crown and extraction (D6740, D7210, D6245) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7230) and the 
anesthesia (D9222 and D9223) for tooth #1 and #32. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
procedures. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the removal of impacted tooth and anesthesia 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 pre-approve the 
removal of impacted tooth (D7230) and the anesthesia (D9222 and D9223) for tooth #1 and #32.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneer (porcelain laminate) - indirect tooth #'s 23, 
24, 25, and 26 (D2962). 
 
You asked the Plan to pre-approve the labial veneer (porcelain laminate). You say that the procedure hasn't 
been done yet but you would like it approved. The Plan denied your request. The Plan says this service is not 
covered under the benefit 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 pre-approve 
labial veneer (porcelain laminate) - indirect tooth #'s 23, 24, 25, and 26 (D2962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure (D4283) 
for tooth #3. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the autogenous connective tissue graft procedure 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
autogenous connective tissue graft procedure (D4283) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional dental implant services (D6051, D6111, 
D6114, D6115, D6118, D6119). 
 
You asked the Plan to pre-approve 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 annual $3,500 dental benefit 
maximum allowance 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 with the Plans authorization of procedure codes 
D6011 and D6191. Therefore, we decided that the Plan does not have to pre-approve additional dental implant 
services (D6051, D6111, D6114, D6115, D6118, D6119).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this provider has always treated you. The Plan 
denied your request. The Plan says you must receive your care from a 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported fixed denture for 
partially edentulous arch  maxillary (D6116), and implant /abutment supported fixed denture for partially 
edentulous arch  mandibular (D6117). 
 
You asked the Plan to pre-approve the dental services represented by codes D6116 and D6117. You say that 
you can't eat properly due to the implants moving around a lot in your mouth. You also say that you are unable 
to eat properly and are losing a lot of weight. The Plan denied your request. The Plan says your supplemental 
dental benefits do not cover implant/abutment supported fixed dentures for partially edentulous arches D6116 
and D6117. 
 
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 
implant /abutment supported fixed denture for partially edentulous arch  maxillary (D6116), and implant 
/abutment supported fixed denture for partially edentulous arch  mandibular (D6117).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #10. 
 
You asked the Plan to pre-approve the dental service. You say that you have pain in your tooth and the dental 
procedure is medically necessary. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because endodontics 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endodontic therapy (D3310) for tooth #10.