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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
denture. 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 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 maxillary 
partial denture (D5211).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office visit provided on March 09, 2022. 
 
You asked the Plan to pay for Office visit. You say that you are appealing the claim payment denial. 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 Office visit provided on 
March 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on June 18, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you feel that you should not 
have to pay the copayment. 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 $50 
copayment for in and out-of-network Medicare-covered urgently needed services. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the in and 
out-of-network Medicare-covered urgently needed services 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an urgent care visit provided on June 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy and retrograde filling (D3410, D3430) 
provided on June 16, 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 an 
apicoectomy and retrograde filling (D3410, D3430) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported retainer (D6068) for tooth #15. 
 
You asked the Plan to pre-approve the dental services. You say that only 1 implant process has been 
performed. The Plan denied your request. The Plan says your benefit for the requested items or 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 the Plan paid for a custom fabricated abutment (D6057) and an abutment supported to crown (D6059) 
for tooth #12 on May 3, 2023. On July 28, 2023, the Plan paid for the surgical placement of implant body 
(D6010) for tooth #10; therefore, your benefit for the requested items or services was exhausted on the date of 
service of July 28, 2023. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated 
abutment (D6057) and an abutment supported retainer (D6068) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis - adult (D1110), bitewings - four 
radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first 
radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230 x2) provided 
on June 13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. The Plan also says your benefit for the 
intraoral - periapical each additional radiographic image 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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for prophylaxis - adult (D1110), bitewings - four 
radiographic images (D0274), periodic oral evaluation - established patient (D0120), intraoral - periapical first 
radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230 x2) provided 
on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on March 23, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that they cover some vaccines under Part D 
prescription drug benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on March 
23, 2022.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of a total knee arthroplasty, with or without 
allograft; femoral and entire tibial component (27487). 
 
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. 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for knee pain and mechanical complication of an internal left knee 
prosthesis. He presented with knee pain that is diffuse over the left knee. The symptoms began 7 years ago and 
is associated with stiffness. The exam reveals a full extension and 30 degrees of flexion.   
 
 
 
He is stable to valgus and varus stress. There is no crepitus. There is pain with attempts at forcing further 
flexion. The x-rays are noted to show a well-placed total knee arthroplasty with osteophyte formation over the 
patella impinging on the lateral femoral condyle. 
 
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. The documentation does not support any physical therapy 
or medication therapy having been tried and failed to restore motion and decrease pain. There are no diagnostic 
imaging studies provided for review; however, are noted on exam to show a well-placed total knee 
arthroplasty. The rationale for a revision arthroplasty is not evident over other procedures to treat arthrofibrosis. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested revision of the left total knee 
arthroplasty is not medically reasonable or necessary. 
 
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 revision of a total knee arthroplasty, with or without allograft; femoral and entire tibial 
component (27487).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 24, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need and require the 
compression stockings urgently. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need the additional miles for a dental 
treatment. The Plan denied your request. The Plan says the service is a covered benefit, but the request will 
exceed the benefit limits set in the agreement for routine transportation.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 142 miles. 
Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of 
routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation miles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a graft for facial nerve paralysis (15840), Rhytidectomy; 
of the cheek, chin, and neck (15828), and Rhytidectomy; superficial of the musculoaponeurotic system 
(SMAS) flap (15829).  
 
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 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the medical records provided, there is no documentation that indicates the 
services at issue in this case meet all Medicare criteria to be considered medically reasonable and necessary.   
 
 
The provided records in this case do not document that the requested procedures are necessary to improve the 
function of a malformed body member; meets, but does not exceed, your medical need; and is furnished in 
accordance with the accepted standards of medical practice for post-stroke care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a graft for facial nerve paralysis (15840), Rhytidectomy; of the cheek, chin, and neck 
(15828), and Rhytidectomy; superficial of the musculoaponeurotic system (SMAS) flap (15829).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on April 3, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that they cover some vaccines under the Part D 
prescription drug benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 3, 
2023.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you experience pain in the cervical spine 
area. The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have pain in the cervical spine area, acupuncture 
is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
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. 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Intracept procedure is experimental. Also, there is no magnetic resonance imaging (MRI) 
showing only modic changes without facet joint degenerative disease or stenosis. The cause of pain is not clear.   
 
  
 
 
 
 
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 the Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network coverage for a left shoulder replacement to 
be rendered by an out-of-network (OON) provider.  
 
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 available with 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve in-network 
coverage for a left shoulder replacement to be rendered 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 continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are appealing the denied 
CGM. 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 CGM questionnaire form from the enrollees 
physician indicates that you do not use insulin or have a history of problematic hypoglycemia. Based on this 
information, we decided that Medicare rules for coverage of the CGM and related supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic retainer crowns (D6740 x 2) and the 
porcelain/ceramic pontic (D6745) provided on July 24, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items at issue 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 items provided are not among those 
covered under this benefit.  
  
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic retainer crowns (D6740 x 2) 
and the porcelain/ceramic pontic (D6745) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), dental cleaning 
(D1110), and the topical application of fluoride varnish (D1206) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by the enrollees 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 the enrollee received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental 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 the 
periodic oral evaluation (D0120), dental cleaning (D1110), and the topical application of fluoride varnish 
(D1206) provided on August 9, 2023.