Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo device. 
 
You asked the Plan to pre-approve Barostim Neo device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a review of the current medical literature does not support this service to be 
reasonable and necessary. There remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim Neo device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
August 9, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service March 23, 2021. Specifically, the 
Plans contract states that one panoramic radiographic image or intraoral complete series of radiographic 
images is covered every three plan years. You previously received an intraoral complete series of radiographic 
images on March 23, 2021, less than three years prior, which were paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) provided on August 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on July 4, 
2023.  
 
You asked the Plan to pay for the ambulance services without transport. You say that the services were 
medically necessary. The Plan denied your request. The Plan says without transport there are no payable 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 4, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services without transport received 
on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown for tooth number 19 (D2740) 
provided on August 10, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the item provided 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 item provided was exhausted on date of service February 17, 2022.  
  
 
 
 
Specifically, the Plans contract states that a dental crown is covered once every five years. You previously a 
dental crown for tooth number 19 on February 17, 2022, less than five years prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the item provided in this case. Therefore, we 
decided that the Plan does not have to pay for the porcelain/ceramic crown for tooth number 19 (D2740) 
provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 03, 2023. 
 
You asked the Plan to pay for lab services. 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 lab services provided on 
July 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant maintenance procedures (D6080 x 4) provided 
on July 27, 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 implant 
maintenance procedures (D6080 x 4) provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator (64561, 64585, 64595). 
 
You asked the Plan to pre-approve a sacral nerve stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered when specific 
criteria are met. 
 
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 sacral nerve stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet the 
coverage criteria detailed in the NCD. The records do not show that the enrollee does not have benign prostatic 
hyperplasia (BPH) with bladder outlet obstruction. Sacral neuromodulation is not indicated for obstructive 
uropathy. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator (64561, 64585, 64595).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-one to three teeth 
per quadrant (D4342 x 3) provided on July 10, 2023 and July 19, 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 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 periodontal scaling and root planing-one to 
three teeth per quadrant (D4342 x 3) provided on July 10, 2023 and July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the frames, the antireflective coating, 
the polycarbonate lens, and the vision supply accessory provided on June 22, 2023. 
 
You asked the Plan to pay for the vision services. You say that that the vendor told you the amount you were 
responsible for, and you paid that amount. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan paid for eyeglasses on May 4, 2022, which exhausted the 
benefit. Based on this information, we decided that the Plan's rules for coverage of the vision services have not 
been met. Therefore, we decided that the Plan does not have to pay for the progressive lens, the frames, the 
antireflective coating, the polycarbonate lens, and the vision supply accessory provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 09, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on July 
10, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. The Plan denied your request. The Plan says 
your benefit for the requested 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 service was exhausted on date of service June 2, 2023 for procedure code 
D0210 intraoral  comprehensive series of radiographic images. Therefore, we decided that the Plan does not 
have to pay for the panoramic radiographic image (D0330) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 19, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the 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 subsequent nursing 
facility care provided on May 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on July 17, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that these services were rendered in good will. 
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 skilled nursing facility 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 21, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that at the time services were rendered, 
the enrollee was residing in a nursing facility. 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 subsequent nursing 
facility care provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation - per 
site (D7953) provided on June 29, 2023. 
 
You asked the Plan to pay more for the bone replacement graft for ridge preservation. You say that you  paid 
$598 for services from your flex account and you are seeking reimbursement for the denied services. The Plan 
denied your request. The Plan says your benefit for the bone replacement graft for ridge preservation $5,000 
dollar limit was met. 
 
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. Specifically, 
the benefit for supplemental dental coverage is limited to $5,000 annually.  The records show that the Plan paid $55 under claim number ending in 36882 for dental services provided on 
July 13, 2023. The record show the Plan paid $64 under claim ending in 26380 for dental services provided on 
June 8, 2023. The records show that the Plan paid $1,883 under claim number ending in 76046 for dental 
services provided on July 13, 2023. The records show that the Plan paid $2,998 under claim ending in 73625 
for dental services provided on June 29, 2023. This means that the Plan paid $5,000 in total for dental services 
provided in 2023. This exhausted the annual dental benefit allowance for the 2023 calendar year. Therefore, we 
decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation - per site 
(D7953) provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 03, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider was not responsible 
for obtaining authorization. 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 subsequent nursing 
facility care provided on April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that it is only reasonable that a new dentist would 
perform an intraoral comprehensive series of radiographic images in commencement of care so they are not 
practicing blindly. The Plan denied your request. The Plan says your benefit for the intraoral  comprehensive 
series of radiographic images 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 service was exhausted on date of service November 4, 2021. Therefore, 
we decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210) provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140), and immediate denture - mandibular (D5140) provided on June 
29, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were never notified that the doctor 
was out of network. You also say that you should not have to check with the plan every time you go to the 
doctor. The Plan denied your request. The Plan says your benefit for the requested services $2,000 dollar limit 
was partially met. 
 
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 services was exhausted on dates of service May 17, 2023, and June 29, 
2023. Your annual maximum has been satisfied and no additional payment will be made towards the appealed 
claim. Therefore, we decided that the Plan does not have to pay more for the extractions, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140), and immediate denture - mandibular (D5140) 
provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided on May 31, 2023. 
 
You asked the Plan to pay for the bone replacement graft. You say that this was an emergency visit due to a 
tooth falling out and you needed to have it fixed fast. You also say that after making the appointment the nurse 
advised you that the insurance would not cover you to which you were not aware that you needed to go a 
specific dental group. The Plan denied your request. The Plan says this service is not covered 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation - per site (D7953) provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a topical 
application of fluoride varnish (D1206), a resin based composite for two posterior surfaces(D2392), a resin 
based composite for one anterior surface (D2330), and caries preventive medicament (D1355) provided from 
May 1, 2023, to June 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know you had a maximum 
benefit of $1,500 for the entire year. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. The Plan also says that caries preventive medicament (D1355) is 
not 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 7, 2023. The record 
also shows that caries preventive medicament (D1355) is not a covered benefit. Therefore, we decided that the 
Plan does not have to pay more for a comprehensive oral evaluation (D0150), a topical application of fluoride 
varnish (D1206), a resin based composite for two posterior surfaces(D2392), a resin based composite for one 
anterior surface (D2330), and caries preventive medicament (D1355) provided from May 1, 2023, to June 7, 
2023.