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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied charge because you 
have not had full x-rays in 4 years, and you have not also had an exam in years. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a comprehensive oral evaluation (D0150) on February 14, 2023; therefore, your benefit 
for the requested item or service was exhausted on the date of service of February 14, 2023. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on September 
7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair. 
 
You asked the Plan to pre-approve the chair. You say that you need a lift chair for daily mobility. You also say 
that you have been requesting a lift chair for three years. The Plan denied your request. The Plan says the chair 
itself does not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a chair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for that laparoscopy surgical procedure provided by a non-
Medicare certified provider on August 22, 2023. 
 
You asked the Plan to pay for that laparoscopy surgical procedure. You say that the out-of-network provider 
was the only available assistant at the time of the procedure. The Plan denied your request. The Plan says the 
rendering provider is a nonparticipating Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for that laparoscopy surgical procedure 
provided by a non-Medicare certified provider on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140 x 3) provided on January 3, 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 the services provided 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 services provided are not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140 x 3) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 16, 2023. 
 
You asked the Plan to pay for wound care supplies. 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 wound care supplies 
provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drugs or medicaments dispensed in the office for 
home use (D9630), and gingival irrigation with a medicinal agent  per quadrant (D4921). 
 
You asked the Plan to pre-approve the drugs or medicaments and gingival irrigation. You say that you are 
requesting for the drugs and medication to be covered for the dental services you need to heal your gums. The 
Plan denied your request. The Plan says codes D9630 and D4921 are not covered dental codes. 
 
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 pre-approve the drugs or medicaments dispensed in the 
office for home use (D9630), and gingival irrigation with a medicinal agent  per quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
pontic-porcelain fused to high noble metal (D6240), and the retainer crowns-porcelain fused to high noble 
metal (D6750 x 3) provided on August 21, 2023. 
 
You asked the Plan to pay for the dental 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 dental items provided 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 dental items provided are not 
among those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required 
(D2950), pontic-porcelain fused to high noble metal (D6240), and the retainer crowns-porcelain fused to high 
noble metal (D6750 x 3) provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (K0898) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a power wheelchair. You say that your current wheelchair is 11 years old. 
You also say that it does not charge and is not safe to use. The Plan denied your request. The Plan says there 
are network providers available. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve the item. Therefore, we decided that the Plan does not have to pre-approve a replacement power 
wheelchair (K0898) 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 waive the coinsurance for ophthalmological services provided on 
June 14, 2023. 
 
You asked the Plan to waive the coinsurance for ophthalmological services. You say that there should be a zero 
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 50% 
coinsurance for vision care. 
 
You have been asked to pay 50% coinsurance for ophthalmological services. This item/service falls within the 
vision care 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 coinsurance for ophthalmological services 
provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and the endodontic therapy (D2740) 
provided on July 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were advised to have your tooth fixed by a 
dentist and send the bill to the Plan. 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 the crown (D2740) and the endodontic therapy (D2740) provided on July 20, 2023. 
  
Your complaint that you are being penalized for your dentists mistake 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 the office visit provided by a chiropractor on April 6, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were informed that the services were covered 
under your Plan. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anticancer treatments to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve anticancer treatments. You say that the requested provider's services are 
easier for you to access. The Plan denied your request. The Plan says rules for coverage for OON services have 
not been met. 
 
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 
anticancer treatments to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus xF liquid biopsy testing, coded as 81455 provided to
the enrollee on August 1, 2022.

You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied
your request. The Plan says this test is not Food and Drug Administration (FDA) approved. Maximus
overturned the Plans denial. The Plan requested a reopen stating Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The documentation does not support that the coverage criteria for the Tempus xF
Panel genetic testing in this case met the coverage criteria for genetic testing. This testing does not have FDA
approval or clearance, and an FDA-approved or FDA- cleared indication for use in this enrollee's condition.
There is also insufficient evidence in the medical literature to support the clinical utility of Tempus xF Panel
testing in this setting. Therefore, we decided that the Plan does not have to pay for Tempus xF liquid biopsy
testing, coded as 81455 provided to the enrollee on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper and lower dentures (D5110, D5120) 
provided on August 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you need new dentures. 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 items was exhausted on date of service July 28, 2022. Therefore, we 
decided that the Plan does not have to pay for the complete upper and lower dentures (D5110, D5120) provided 
on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140) 
and the intraoral-periapical first radiographic image (D0220) provided on September 25, 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 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.   
 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation-problem focused 
(D0140) and the intraoral-periapical first radiographic image (D0220) provided on September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the infectious disease outpatient office visits to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient office visit. You say that you have sought out professional 
help from infectious disease and have been denied and you would like to appeal the denial decision. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 infectious disease outpatient office visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee x-rays provided on August 01, 2023. 
 
You asked the Plan to pay for knee x-rays. You say that the provider is a Medicare-certified 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 knee x-rays provided on 
August 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot x-rays provided on August 02, 2023. 
 
You asked the Plan to pay for foot x-rays. You say that these services were medically necessary. 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 foot x-rays provided on 
August 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride varnish (D1206) provided on July 
27, 2023. 
 
You asked the Plan to pay for the dental service. You say that the services should be covered, and it was hard 
to find a participating provider in your area. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the application of fluoride varnish 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
application of fluoride varnish (D1206) provided on July 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable drug delivery systems (A4305) and supplies 
(A4223) provided from July 2, 2023, to July 26, 2023. 
 
You asked the Plan to pay for disposable drug delivery systems and supplies. You say that these items are 
covered by Medicare. The Plan denied your request. The Plan says these items are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-
covered items. 
 
We looked at the file and Medicare rules. Disposable drug systems and the supplies used with them are non-
covered. Based on this information, we decided that Medicare rules for coverage of disposable drug delivery systems and supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
disposable drug delivery systems (A4305) and supplies (A4223) provided from July 2, 2023, to July 26, 2023.