Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says this 
item is not covered by your Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of osteoporosis with a history or rheumatoid arthritis and systemic steroid 
therapy. The documentation does not support that the enrollee has tried and failed one oral bisphosphonate 
(such as alendronate, risedronate) and one intravenous bisphosphonate therapy (such as zoledronic acid). The 
documentation does not support that one oral bisphosphonate (such as alendronate, risedronate) and one 
intravenous bisphosphonate therapy (such as zoledronic acid) would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9940). 
 
You asked the Plan to pre-approve the occlusal guard. You say you were advised by the dentist you grind your 
teeth while you sleep and to prevent further damage you need the occlusal guard.  The Plan denied your 
request. The Plan says this service is 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 an 
occlusal guard (D9940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported crown (D6068) for tooth #10. 
 
You asked the Plan to pre-approve the dental services. You say that you were told you had up to $5,000 for 
dental coverage and all procedures should be covered up to that amount. 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 approved 2 custom fabricated abutments (D6057) and 2 abutment supported crowns (D6068) 
for tooth #7 and #9 on January 19, 2023; therefore, your benefit for the requested item or service was exhausted 
on the date of approval of January 19, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and abutment supported crown (D6068) for tooth #10.  
 
Your complaint about the salesperson 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on 
September 19, 2022. 
 
You asked the Plan to pay for transitional care management services. You say that the enrollee could not 
choose an in-network provider. 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 transitional care 
management services provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that your dental benefit limit of $5,000 has not 
been met. 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 authorization A0230328139174. 
Therefore, we decided that the Plan does not have to pre-approve surgical access to an implant body  
(D6011 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) and prefabricated post and core in 
addition to crown (D2954) for tooth number 29. 
 
You asked the Plan to pre-approve the dental services. You say that you require these procedures because your 
tooth decayed causing the crown to fall off. 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 dates of service July 23, 2020, and 
December 4, 2020. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) and 
prefabricated post and core in addition to crown (D2954) for tooth number 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodic oral evaluation - established patient (D0120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to see the out-of-network 
provider. 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 periodic 
oral evaluation - established patient (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that your previous denture gives you problems 
while eating and you need to replace the denture. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of May 25, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6240, D6750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not meet the clinical requirements to be approved. 
 
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 
covered, however, the records indicates that you do not meet the clinical requirements to be approved. 
Therefore, we decided that the Plan does not have to pre-approve a pontic and retainer crown (D6240, D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with procedure code 94761 for 
date of service August 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with procedure code 94761 for date of service August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) for all 
4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services because they are medically necessary. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the periodontal scaling and root planing is not covered by 
the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like services provided by an 
out-of-network provider. 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.
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 the CGM. You say that you are taking insulin and you need the CGM to 
control your glucose. 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 for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 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 extractions and a partial denture to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that there are no in-network providers within 50 
miles of you. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental benefits. Also, it was verified that there are multiple in-network providers 
avialable that can provide the requested 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. 
 
  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 extractions 
and a partial denture to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve precision attachment, by report (D5862), overdenture  
complete mandibular (D5865) and surgical access to an implant body (second stage implant surgery) (D6011). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services to help with 
eating and other health issues. The Plan denied your request. The Plan says these services are not covered 
under your 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. Precision attachment, by 
report (D5862), overdenture  complete mandibular (D5865) and surgical access to an implant body (second 
stage implant surgery) (D6011) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5862, D5865 and 
D6011 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve precision attachment, by report (D5862), overdenture  complete mandibular (D5865) and surgical 
access to an implant body (second stage implant surgery) (D6011).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nutrition therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the nutrition therapy services. You say that you were recommended to see 
this out-of-network provider. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
the nutrition therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments (97814). 
 
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 you do not meet criteria for coverage of the 
requested services. 
 
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, the acupuncture services in this case have not been 
requested on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture treatments (97814).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch blood glucose strips. 
 
You asked the Plan to pre-approve the OneTouch blood glucose strips. You say that your doctor states other 
meters give you false readings and you can only use the OneTouch Verio reflect with device kit. 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 OneTouch blood glucose strips. Therefore, we decided that the Plan does not have to pre-approve 
OneTouch blood glucose strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutment (D6191), semi-precision 
attachment (D6192) and modification of removable prosthesis following implant surgery (D5875). 
 
You asked the Plan to pre-approve these dental services. You say that this is not a covered service. The Plan 
denied your request. The Plan says this is 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 
semi-precision abutment (D6191), semi-precision attachment (D6192) and modification of removable 
prosthesis following implant surgery (D5875).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment 
supported crown (D6059) for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that you would like the dental procedures to be 
approved. 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 approved 2 custom fabricated abutments and 2 abutment supported crowns for tooth #3 and #4 
on February 14, 2023; therefore, your benefit for the requested items or services was exhausted on the date of 
approval of February 14, 2023. Therefore, we decided that the Plan does not have to pre-approve the custom 
fabricated abutment (D6057) and abutment supported crown (D6059) for tooth #20.