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

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing 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 December 6, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete series of x-ray images (D0210) 
provided on January 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (93228). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 external mobile cardiovascular 
telemetry. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found one episode of short-lived palpitation without syncope can 
be monitored by traditional Holter or event monitoring and does not require a multi-lead instantaneous 
physician monitoring test. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry (93228).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (D9944) 
provided on February 14, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that the occlusal guard was recommended as a 
treatment for your temporomandibular joint (TMJ) and to help reduce inflammation with your eustachian tubes. 
The Plan denied your request. The Plan says the procedure in dispute, D9944, is not listed on the dental benefit 
chart as 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 an 
occlusal guard  hard appliance, full arch (D9944) provided on February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of endosteal implant. 
 
You asked the Plan to pre-approve the dental services. You say that you need this procedure because you 
cannot chew your food. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of endosteal implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 6, 8, and 9 
(D6740), adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant 
and malignant lesions, not to include cytology or biopsy procedures (D0431), topical application of fluoride 
varnish (D1206), and gingival irrigation  per quadrant (D4921), and pontic - porcelain/ceramic tooth #7 
(D6245). 
 You asked the Plan to pre-approve the dental services represented by codes D6740, D0431, D1206, D4921, and 
D6245. The Plan denied your request. The Plan says the dental codes D6740, D0431, D1206, D4921, and 
D6245 are not listed as covered dental 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 a 
retainer crown - porcelain/ceramic tooth #'s 6, 8, and 9 (D6740), adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431), topical application of fluoride varnish (D1206), and gingival irrigation  per 
quadrant (D4921), and pontic - porcelain/ceramic tooth #7 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you had a partial denture done last summer 
but over the past few months it is useless. You also say that you lost the teeth that it was hooked too and no 
longer have them in your mouth. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 28, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and post and core (D2954). 
 
You asked the Plan to pre-approve a crown and post and core. 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 pre-approve a 
crown (D2740) and post and core (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E2361 x2, E1028 x6, E2377, E2313, E1002, 
E2620, E1012, E2311, and E2609). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option and 
additional items and accessories. The Plan denied your request. The Plan says the enrollee does not meet the 
rules for a group 3 power wheelchair to be covered. The Plan also says the enrollee resides in a SNF, with no 
plans of going home, and the power wheelchair was requested as a convenience for the staff where the enrollee 
lives. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a group 3 standard power wheelchair with single power option and additional items and 
accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have 
to pre-approve a group 3 standard power wheelchair with single power option (K0856) and additional items 
and accessories (codes E2361 x2, E1028 x6, E2377, E2313, E1002, E2620, E1012, E2311, and E2609).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on June 
13, 2022, to November 29, 2022. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you should not have a 
copayment for these services. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 amount you owe is $160 ($40 copayment 
x 4 visits = $160). Therefore, we decided that the Plan does not have to waive the copayment for each specialist 
office visit provided on June 13, 2022, to November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8. 
 
You asked the Plan to pre-approve the dental service. You say that the requested crown is medically necessary, 
and you do not want to lose the tooth. 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 2 crowns on February 27, 2023; therefore, your benefit for the requested item or 
service was exhausted on the date of service of February 27, 2023. Therefore, we decided that the Plan does not 
have to pre-approve a crown (D2751) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endodontic therapy (D3320) provided on March 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this root 
canal. 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 an endodontic therapy (D3320) provided on March 14, 2023.
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 you are legally blind, and you need this to monitor 
your glucose level. The Plan denied your request. The Plan says the enrollee is not being treated with insulin. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and complete 
denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the mandibular and maxillary dentures. The Plan denied your request. The 
Plan says these services are not covered under the benefit package. 
 
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 
complete denture - mandibular (D5120), and complete denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay provided from 
January 18, 2023, to January 19, 2023. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that you would like this 
processed as in-network. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network inpatient hospital 
care. The Plan contract also clearly says that enrollees must pay 30% coinsurance after meeting the deductible 
for out-of-network inpatient hospital care. 
 
You have been asked to pay $914.77 toward the deductible. The item or service you asked the Plan to waive 
the cost share for falls within the inpatient hospital care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to out-of-network inpatient 
hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient 
hospital stay was received on January 18, 2023, to January 19, 2023.  
 
You have also been asked to pay $184.49, which is less than the standard 30% coinsurance for the inpatient 
hospital stay. This item/service falls within the inpatient hospital care benefit category. You have been asked to 
pay a total of $1,099.26 ($914.77 deductible + $184.49 coinsurance = $1,099.26). 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. Therefore, we decided that the Plan does not have 
to waive the cost share for the inpatient hospital stay provided from January 18, 2023, to January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that you need the FreeStyle Libre 3 
sensor. The Plan denied your request. The Plan says you are requesting a CGM product that does not meet 
Medicare's definition of durable medical equipment (DME) and, therefore, is not in a defined Medicare benefit 
category. 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on November 30, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that this should be covered as it is 
medically necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. Therefore, the decision is upheld. 
 
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 an electrocardiogram (ECG) provided on 
November 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that you are appealing the denied Dexcom 
G7 sensor. 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 continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G7 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and complete 
denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dentures. 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 complete denture - mandibular (D5120) was exhausted on date of service August 16, 
2021. The record also shows that the complete denture  maxillary (D5110) was exhausted on May 2, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), 
and complete denture - maxillary (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that you prefer to use the Dexcom G7 
sensor because that was what your provider wants you to use. The Plan denied your request. The Plan says only 
the preferred brand products listed in the EOC are covered. The Plan also says that in order to meet criteria for 
a Dexcom device, you would have to fail use of the preferred device (Freestyle Libre) and currently be taking 
insulin or have documentation of hypoglycemic episodes that did not improve after regimen changes. 
 
 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 the Dexcom G7 sensor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the enrollee should try to get a Dexcom G7, if 
covered. 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 the Dexcom G7. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7.