Persius/hicric huggingface dataset:
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 you have problems with your old dentures. 
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 your benefit for the requested item or service was exhausted on the date of service of February 11, 2021. 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom orthotics.  
 
You asked the Plan to pre-approve the custom orthotics. You say that you have constant pain in your foot and 
the requested insert are necessary to support your foot. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the custom orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site 
(D4266) provided on August 24, 2022. 
 
You asked the Plan to pay for the guided tissue regeneration - resorbable barrier, per site (D4266) provided on 
August 24, 2022. You say that the extraction was a result of the fainting accident you had. The Plan denied 
your request. The Plan says this dental service (unless related to a surgery of the jaw/facial bone) isnt covered 
by your medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for guided tissue regeneration - 
resorbable barrier, per site (D4266) provided on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reline complete mandibular denture (indirect) (D5751). 
 
You asked the Plan to pre-approve the dental services. You say that you have not used all of your allowable 
amount. 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. This benefit includes the 
requested item or service but is limited to one every one year per patient. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered reline complete mandibular denture (indirect) (D5751) on April 20, 2023. 
Therefore, this benefit was exhausted as of April 20, 2023. Therefore, we decided that the Plan does not have to 
pre-approve reline complete mandibular denture (indirect) (D5751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  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 freestyle libre 2 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261), a dispensing fee (V5160), and a 
hearing aid assessment (V5010) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says hearing aids and a hearing exam must be 
purchased through the Plan's select hearing aid provider to be covered.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the Plans contract states that hearing aids and 
hearing exams must be purchased through the Plans select hearing aid provider to be covered. However, your 
request in this case is for hearing aids/services to be provided by an out-of-network vendor. Therefore, we 
decided that the Plan does not have to pre-approve hearing aids (V5261), a dispensing fee (V5160), and a 
hearing aid assessment (V5010) to be rendered 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 lower partial denture (D5225). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service September 22, 2021. Specifically, 
the Plans contract states that complete or partial dentures are covered every five years.  
  
 
 
You previously received a lower partial denture on September 22, 2021, less than five years prior, which was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for the dental item requested in this 
case. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis Transmitter.  
You asked the Plan to pre-approve the Dexcom G6 Mis Transmitter. The Plan denied your request. The Plan 
says a  CGM is not covered under Medicare if the enrollee is not on insulin or does not have documentation of 
recurrent problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 Mis Transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 Mis Transmitter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0156). 
 
You asked the Plan to pre-approve home health 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 are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
 
  The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health services (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5225) and an upper partial 
denture (D5226). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 March 14, 2022.  
  
 
 
Specifically, the Plans contract states that one complete or partial denture per arch is covered every five years. 
You previously received one upper and lower partial denture on March 24, 2022, less than five years prior, 
which were paid for by the Plan. Therefore, you have exhausted the allowable benefit at this time. Therefore, 
we decided that the Plan does not have to pre-approve a lower partial denture (D5225) and an upper partial 
denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3D dental surface scan  direct (D0801) and bone 
replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. 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. A 3D dental surface scan  
direct (D0801) and bone replacement graft for ridge preservation - per site (D7953) are not covered under the 
Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0801 and D7953 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
3D dental surface scan  direct (D0801) and bone replacement graft for ridge preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported to a denture (D6111). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
implant supported to a denture 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported to a denture (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) Tooth #3 and 5 and 
core buildup, including any pins when required (D2950) Tooth #3 and 5.  
 
You asked the Plan to pre-approve the dental services. You say that the enrollee would benefit from the 
requested services. 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. This benefit includes the 
requested D2740 and D2741 but are limited to one of (D2740, D2750, D2751, D2752, D2753, D2783, D2790, 
D2791, D2792, D2794) per 60 month(s) per patient, same tooth and D2950 but is limited to one of (D2950, 
D2952, D2954) once per tooth per 60 months, per patient. Deny when billed with resin or amalgam restoration 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered crown - porcelain fused to predominantly base metal (D2741) Tooth # 3 and 5 
on October 16, 2019, and a core buildup, including any pins when required (D2950) Tooth #3 and 5. Although 
D2741 and D2740 are two different services, they fall within the same category in your Evidence of Coverage 
and are subject to the same frequency limitations. Therefore, these benefits were exhausted as of October 16, 
2019. Therefore, we decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) 
Tooth #3 and 5 and core buildup, including any pins when required (D2950) Tooth #3 and 5.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for mammography on February 06, 2023. 
 
You asked the Plan to waive the coinsurance for mammography. You say that you feel that this is unfair 
because the mammogram is a covered preventative service. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out-of-network mammogram at a specialists office, freestanding radiological facility and 
outpatient hospital. Covered services include one baseline mammogram between the ages of 35 and 39, one 
screening mammogram every 12 months for women aged 40 and older and clinical breast exams once every 24 
months. The provider billed in the amount of $440 and the allowed is $63.52 for the service. $63.52 x 40% = 
$25.41. Therefore, results in the total cost sharing amount of $25.41. 
 
You have been asked to pay a 40% coinsurance for mammography. This item/service falls within the breast 
cancer screening (mammograms) 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 
mammography on February 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve D9120. You say that you are in severe pain. The Plan denied your request. 
The Plan says this is not a covered dental 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, 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 a 
fixed partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your denture broke, and you need a new 
one. 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 August 19, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab testing on January 30, 2023.  
 
You asked the Plan to waive the coinsurance for lab testing. You say that you cannot afford this bill. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for genetic testing. Covered services include but are not limited to laboratory tests. The provider 
billed in the amount of $2,735 and the allowed amount is $1,824.88 for the service. $1,824.88 x 20% = 
$364.98. Therefore, results in the total cost sharing amount of $364.98. 
 
 
 You have been asked to pay a 20% coinsurance for lab testing. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 lab testing on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial 
denture (D5214, D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial and the services are medically necessary. 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 October 19, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular 
partial denture (D5214, D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on December 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the providers website says they are in-
network with the Plan. 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 December 28, 2022. 
Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on December 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the oxygen concentrator, and the portable 
gaseous oxygen system provided by an in-network provider on February 24, 2023. 
 
You asked the Plan to waive the deductible for the oxygen concentrator, and the portable gaseous oxygen 
system. You say that you do not agree with the member responsibility. 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. Your 
contract with the Plan says that there is a $625 deductible which applies to durable medical equipment (DME) 
and related supplies.  
 
 
 
 
 You have been asked to pay a $87.52 deductible for the oxygen concentrator, and the portable gaseous oxygen 
system. The items or services you asked the Plan to waive the deductible for fall within the durable medical 
equipment (DME) and related supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $625 deductible which applies to durable medical equipment (DME) 
and related supplies. This cost sharing is a contractual obligation that had not been met at the time the oxygen 
concentrator, and the portable gaseous oxygen system was provided on February 24, 2023. Therefore, we 
decided that the Plan does not have to waive the deductible for the oxygen concentrator, and the portable 
gaseous oxygen system provided by an in-network provider on February 24, 2023.