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

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this was a covered 
procedure and you have $4,000 in covered dental benefits. 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 March 23, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 
23, 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 the Plan did not get to this in a 
timely manner. You also say that the enrollee wants to be able to get this through the pharmacy. 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 the massage therapy (97124) provided on February 8, 2023 
and February 15, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the massage therapy (97124) provided on February 8, 2023 and  
February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #7, #8, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that your previous bridge was poor quality and 
a new bridge is needed. 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 the pontics (D6245) for tooth #7, #8, and #10 on October 19, 2020; therefore, your 
benefit for the requested items or services was exhausted on the date of service of October 19, 2020. Therefore, 
we decided that the Plan does not have to pre-approve pontics (D6245) for tooth #7, #8, and #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutrition drink powder provided. 
 
You asked the Plan to pre-approve nutrition drink powder provided. You say that you have been treated for 
wounds since 2021, and have made progress due to consuming this nutrition drink powder. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve  nutrition drink powder provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
14, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that this was your first dental 
procedure of the year. The Plan denied your request. The Plan says your benefit for the panoramic radiographic 
image has already been exhausted. The Plan also says that per your claim history payment was issued for code 
D0210 for date of service March 24, 2021. 
 
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 panoramic radiographic image was exhausted on date of service March 24, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee presented to the emergency 
department (ED) on May 24, 2023, complaining of low back pain and left leg discomfort particularly her 
knee. No red flag was described in the ED notes; therefore, the medical necessity of the requested MRI lumbar 
spine has not been established without a trial of conservative therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision abutment placement (D6191) and a 
semi-precision abutment attachment (D6192) for tooth #8. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services is the final 
stage and the enrollee cannot eat hard or strong food. 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 pre-approved a semi-precision abutment placement (D6191) and a semi-precision abutment 
attachment (D6192) for tooth #5 and #11 on February 17, 2023; therefore, the enrollees benefit for the 
requested items or services was exhausted on the date of approval of February 17, 2023. Therefore, we decided 
that the Plan does not have to pre-approve a semi-precision abutment placement (D6191) and a semi-precision 
abutment attachment (D6192) for tooth #8.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says the services by an OON provider do not meet the 
requirements for approval. 
 
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 
physical therapy (PT) services 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 a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's current dentures do not fit 
properly, and they cannot functionally chew. 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 enrollees benefit for the requested items or services was exhausted on the date of service of October 
31,2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) 
and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement socket, below knee, molded to patient model 
(L5700). 
 
You asked the Plan to pre-approve a replacement socket. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the requested socket exceeds your need. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a replacement socket. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found medical records, including records from the prescribing physician on July 6, 2023, 
submitted in the appeal confirmed the history of weight loss and an ill-fitting socket, wounding your residual 
limb, and accounting for the prescription of a new socket. The Plans initial objections should have been 
resolved by this documentation, which is very consistent with, and typical of, an active amputee such as you for 
whom periodic socket replacement is reasonable and necessary per Medicare rules. Therefore, L5700 is hereby 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement socket have been met. Therefore, we decided that the Plan has to 
pre-approve a replacement socket, below knee, molded to patient model (L5700).  
 
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 pay for the removal of an impacted tooth - soft tissue tooth #13 
(D7220) provided on October 4, 2022. 
 
You asked the Plan to pay for the removal of an impacted tooth. The Plan denied your request. The Plan says 
procedure code D7220 removal of impacted tooth - soft tissue is not listed as a covered benefit.  
 
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, removal of an impacted tooth is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of an impacted tooth - soft tissue tooth #13 (D7220) provided on October 4, 2022.   
Your complaint about the services and provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330), localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), and 
gingival irrigation  per quadrant (D4921) provided on March 2, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D1330, D4381 and D4921. You say that 
your dentist indicated that these services would be covered by your insurance. The Plan denied your request. 
The Plan says these services are not a covered expense 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral hygiene 
instructions (D1330), localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381), and gingival irrigation  per quadrant (D4921) provided on March 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewing x-rays-four radiographic images (D0274) 
provided on April 11, 2023. 
 
You asked the Plan to pay more 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 you are responsible for a 50% coinsurance applied to the billed amount for this service rendered 
by an out-of-network provider. Additionally, the plan paid this service at the least costly method of treatment. 
 
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 $41.50 (Plans allowed amount of $83 x 50% coinsurance) for the dental service 
rendered by an out-of-network provider. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. Specifically, the bitewing x-rays-four radiographic images provided in this case and billed by the 
dental provider are not a covered benefit. However, the Plans contract provides supplemental coverage for 
bitewing x-rays, one set of x-rays, two times per year. Therefore, this service was paid for by the Plan at the 
least costly method of treatment which applies a coinsurance liability when rendered by an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay more for the bitewing x-rays-four 
radiographic images (D0274) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services from an OON provider. 
 
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 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 dental 
services from an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on March 13, 2023, through 
March 14, 2023. 
 
You asked the Plan to pay for the medication. You say that you were told not to bring personal medicine. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on March 13, 2023, through March 14, 2023. 
  
Benefits for the medication 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that x-rays were performed and the enrollee has 
undergone over 4 months of conservative care. The Plan denied your request. The Plan says that the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has had lateral elbow tendon release 
in the past. He has done home exercises and other conservative measurements. He has had steroid injection 
with some but temporary pain relief. The conservative treatment, especially steroid injection, qualifies him for 
MRI of the left elbow. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of an upper extremity joint.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an MRI provided on November 4, 2022. 
 
You asked the Plan to waive the cost share for an MRI. You say that you are always getting billed $100 when 
you have a visit with the provider and do not understand why. 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 20% 
coinsurance with a limit of $75 per day for diagnostic radiology services.  
 
You have been asked to pay $75 for an MRI. The total cost applied is less than 20% of the allowed amount 
($437.40 allowed x 20% = $87.48) due to the limit of $75 per day. This item/service falls within the outpatient 
diagnostic tests 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 cost share for an MRI provided on 
November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130) provided on 
February 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan representative you spoke with said this 
was a covered benefit. 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 pay for the 
maxillary immediate denture (D5130) provided on February 10, 2023.
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. The Plan denied your request. The Plan says the 
evidence shows you are not suffering from active venous stasis ulcers, or any burn and/or recent surgical 
wound that need compression garment to secure dressings. 
 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.