Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this should not be performed because the enrollee has a pacemaker. 
 
The Plan must follow Medicare rules. Medicare rules say that wireless capsule endoscopy should not be used in 
patients with a cardiac pacemaker or other implanted electromagnetic device. 
 
We looked at the file and Medicare rules. The record shows that the enrollee has a pacemaker. Based on this 
information, we decided that Medicare rules for coverage of a wireless capsule endoscopy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
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 a Dexcom G7. You say that the enrollee would benefit from a CGM. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for a CGM. 
 
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 or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic retainer crown and porcelain fused to 
noble metal retainer crown (D6740, D6752) provided on May 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 11, 2023 (D6740, 
D6752). Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic retainer crown and 
porcelain fused to noble metal retainer crown (D6740, D6752) provided on May 11, 2023.
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. The Plan denied your request. The Plan says the 
Dexcom G7 is a non-preferred brand and there is no documentation why the preferred product in not clinically 
appropriate for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Freestyle Libre CGMs. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G7 sensor have not been met. 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 pay for a limited oral evaluation and intraoral x-ray (D0140, D0220) 
provided on April 4, 2023.  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the intraoral x-rays has already 
been exhausted. Moreover, you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.   
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral x-rays was exhausted on date of service March 1, 2023 (D0220). Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation and intraoral x-ray (D0140, D0220) 
provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265), non-autogenous connective tissue graft for the first tooth (D4275), non-autogenous 
connective tissue graft for each additional contiguous tooth (D4285) and debridement and contouring of peri-
implant defect (D6102). 
 
  You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265), 
non-autogenous connective tissue graft for the first tooth (D4275), non-autogenous connective tissue graft for 
each additional contiguous tooth (D4285) and debridement and contouring of peri-implant defect (D6102). You 
say that you are appealing the denial of dental gum work, because you do not think it has anything to do with 
implants. The Plan denied your request. The Plan says your Plan does not cover these procedures. 
 
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 
biologic materials to aid in soft and osseous tissue regeneration (D4265), non-autogenous connective tissue 
graft for the first tooth (D4275), non-autogenous connective tissue graft for each additional contiguous tooth 
(D4285) and debridement and contouring of peri-implant defect (D6102).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for a comprehensive oral evaluation, intraoral x-rays, 
2D oral/facial photographic image, cone beam computed tomography (CT) scans, and oral hygiene instructions 
(D0150, D0230 x5, D0350 x4, D1330, D0367) provided on August 7, 2023.  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the intraoral x-rays and oral 
evaluations has already been exhausted. Coverage for the 2D oral/facial photographic image, cone beam 
computed tomography (CT) scans, and oral hygiene instructions 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 7, 2023 (D0230) 
and September 30, 2022 (D0150). Moreover, this benefit does not include 2D oral/facial photographic images, 
cone beam computed tomography (CT) scans, or oral hygiene instructions. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation, intraoral x-rays, 2D oral/facial photographic image, 
cone beam computed tomography (CT) scans, and oral hygiene instructions (D0150, D0230 x5, D0350 x4, 
D1330, D0367) provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal root planing and scaling (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 12, 2023, and 
August 16, 2023. Therefore, we decided that the Plan does not have to pre-approve periodontal root planing 
and scaling (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) and to pay 
for a determination of refractive state (92015) on August 9, 2023 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you had a capsule in your 
left eye shattered during a cataract procedure in October of 2022, and have extensive eye issues. You also say 
that you also had a scratched cornea, and under the circumstances it was necessary or you to have a second 
prescriptive eyewear corrective assessment. 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 specialist's office visit. A determination of refractive state is not covered with a medical eye 
examination. 
 
You have been asked to pay a $40 copayment for a specialist office visit (99213). This item/service falls within 
the specialist's office visit 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 rules also say that Original Medicare does not cover routine eye examinations (eye 
refractions). Therefore, we decided that the Plan does not have to waive the copayment for a specialist office 
visit (99213) and to pay for a determination of refractive state (92015) on August 9, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve the foot orthotics. You say that these inserts are needed to support your 
ankles. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014) and a determination of refractive 
state (92015) provided on July 13, 2023. 
 
You asked the Plan to pay for an eye examination (92014) and a determination of refractive state (92015). You 
say that per Medicare guidelines, coordination care plans are generally required to reimburse non-contracting 
providers or at least the Original Medicare rate for Medicare covered services. The Plan denied your request. 
The Plan says per your EOC, you must use Plan network providers for these services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use Plan network providers for your services. 
 
We looked at the file and the Plan's rules. The Plan rules say you must use Plan network providers for vision 
services. Based on this information, we decided that the Plan's rules for coverage of an eye examination 
(92014) and a determination of refractive state (92015) have not been met. Therefore, we decided that the Plan 
does not have to pay for an eye examination (92014) and a determination of refractive state (92015) provided 
on July 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospital admission. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee was involuntarily 
admitted for acute inpatient psychiatric hospitalization on August 30, 2023 with Schizoaffective Disorder 
Bipolar Type, Partial Remission, and Borderline Personality Disorder. Based upon the review of the records 
provided, it was not expected that this enrollee would improve in a reasonable period of time as she did not 
have dangerousness to self or others, was not showing any auditory/visual hallucinations, or any aggressive 
behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The 
health plans denial of inpatient psychiatric services appears appropriate. This enrollee does not appear to 
require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with 
care without any aggressive behaviors. It does not appear that active treatment was taking place. It does not 
appear that the services are reasonably expected to improve the enrollees condition or are for the purpose of a 
diagnosis. It does appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, this enrollee does not meet criteria for coverage of acute inpatient mental health 
treatment as she was not shown to be a danger to herself or others and did not have auditory or visual 
hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acute inpatient psychiatric hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740), and pontics (D6245). 
 
You asked the Plan to pre-approve D6740 and D6245. You say that you need this dental work. The Plan denied 
your request. The Plan says the denied dental services 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 pre-approve 
retainer crowns (D6740), and pontics (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 18 (D2740) 
and a core buildup, including any pins when required for tooth number 18 (D2950).  
 
You asked the Plan to pre-approve the dental items. 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 items 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 items was previously exhausted.   
 
 
Specifically, the Plans contract states that a dental crown is covered once every 60 months. You previously 
received this dental item on January 5, 2021, less than 60 months prior, which was paid for by the Plan. 
Additionally, the Plans contract states that a core buildup is covered once every 60 months. You previously 
received this dental item on September 8, 2020, less than 60 months prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for the dental items requested in this case. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 18 (D2740) and 
a core buildup, including any pins when required for tooth number 18 (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the chest to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve an MRI of the chest. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says you must get your care from network providers that are 
affiliated with your PCPs medical group. 
 
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 
an MRI of the chest to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two series of hearing tests, two digital hearing aids, and 
two hearing aid examinations with an out-of-network provider. 
 
You asked the Plan to pre-approve two series of hearing tests, two digital hearing aids, and two hearing aid 
examination. You say that you need hearing aids to be able to hear during everyday activities and doctor's 
appointments. The Plan denied your request. The Plan says the provider listed is not in your network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you obtain your hearing services from the Plan selected hearing provider or vendor.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of two series of hearing tests, two digital hearing aids, and two hearing aid examination have not been 
met. Therefore, we decided that the Plan does not have to pre-approve two series of hearing tests, two digital 
hearing aids, and two hearing aid examinations with an out-of-network provider.