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

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), a 
cleaning (D1110), the application of fluoride, and a resin-based composite (D2392) provided by an out-of-
network provider on May 16, 2023, and August 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentist office did not check if they were in-
network, and they suggested the fluoride treatment. 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 a periodic oral evaluation (D0120), bitewings (D0274), a cleaning (D1110), the application of 
fluoride, and a resin-based composite (D2392) provided by an out-of-network provider on May 16, 2023, and 
August 18, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided on May 18, 2023. 
 You asked the Plan to pay for the hospital care. You say that the services were provided prior to the hospice 
enrollment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital care provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #6 provided on June 13, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that when you called it was confirmed that you 
did not owe any feed and the services were covered. The Plan denied your request. The Plan says your 
maximum dental benefit for the year 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 $244.22 for dental services on January 3, 2023. On April 19, 2023, the Plan paid $141.60 
for dental services. On June 13, 2023, the Plan paid $1,614.18 for dental services. For the year of 2023 the Plan 
paid $2,000 ($244.22 paid + $141.60 paid + $1,614.18 paid) for dental services; therefore, your annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of June 13, 2023. Therefore, we 
decided that the Plan does not have to pay more for a crown (D2740) for tooth #6 provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the complete lower denture (D5120) 
provided on July 5, 2023. 
 
You asked the Plan to issue additional payment 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 July 5, 2023.  
  
 
Specifically, the Plans contract states that the maximum annual dental benefit is $1,500. The Plan previously 
issued payment in the amount of $1,500 ($1,478 + $22) on February 20, 2023 and July 30, 2023 accordingly 
for dental items/services provided in the 2023 calendar year. Therefore, you have exhausted the allowable 
benefit for the dental item provided in this case. Therefore, we decided that the Plan does not have to issue 
additional payment for the complete lower denture (D5120) provided on July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TheraSkin, per sq cm (Q4121). 
 
You asked the Plan to pre-approve TheraSkin. 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 Chronic Wounds are defined as wounds that do not 
respond to standard wound treatment for at least a 30 day period during organized comprehensive conservative 
therapy. 
 
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 TheraSkin. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Mohs surgery is recommended for both 
lesions. The request is for TheraSkin skin substitute to faciitate healing. Coverage for these skin substitute 
products is not approve for acute skin wounds (Mohs). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TheraSkin, per sq cm (Q4121).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns-porcelain/ceramic (D2740 x2), dental case 
management (D9992 x2), prefabricated post and core in addition to crown (D2954), core buildup (D2950 x2) 
and an invalid procedure code (D0001) provided on May 5, 2022 to April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the crowns shouldn't have been denied as these 
were replacements, not cosmetic, and the originals were done in 2007. The Plan denied your request. The Plan 
says your benefit for the crowns has already been exhausted. The Plan also says dental case management, 
prefabricated post and core in addition to crown, core buildup and an invalid procedure code are not covered 
under 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, certain limitations apply. The record 
shows your benefit for crowns (D2740 x2) was exhausted on date of service June 28, 2022. Therefore, we 
decided the Plan does not have to pay for two additional crowns (D2740 x2). In addition, though the Plan offers 
a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for dental case management 
(D9992 x2), prefabricated post and core in addition to crown (D2954), core buildup (D2950 x2) and an invalid 
procedure code (D0001) provided on May 5, 2022 to April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and the copayment for a specialist office visit 
(99214) provided on May 2, 2023. 
 
You asked the Plan to waive the deductible and the copayment for a specialist office visit (99214). You say that 
the Plan covers one annual hearing examination at no cost. You also say you were charged and paid $77.08 to 
the provider's facility. 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 $233 deductible which applies to services from a specialist or under 
certain circumstances, treatment by a nurse practitioner, physician's assistant or other non-physician health care 
professional in a specialist's office.  
 
 
  You have been asked to pay $77.08 toward the deductible for an office visit (99214). You have also been asked 
to pay an $18 copayment toward the office visit (99214). The item or service you asked the Plan to waive the 
deductible and the copayment for falls within the services from a specialist or under certain circumstances, 
treatment by a nurse practitioner, physician's assistant, or other non-physician health care professional in a 
specialist's office benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $233 deductible which applies to services from a specialist or under certain circumstances, 
treatment by a nurse practitioner, physician's assistant, or other non-physician health care professional in a 
specialist's office. This cost sharing is a contractual obligation that had not been met at the time a specialist 
office visit (99214) was received on May 2, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible and the copayment for a specialist office visit (99214) provided on May 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lansoprazole. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lansoprazole.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you already had an authorization 
approved previously. The Plan denied your request. The Plan says that acupuncture is only covered for chronic 
low back pain. 
 
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, you have abdominal pain, and acupuncture is only 
covered for chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit from LTACH services. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health Plan. Given there are offered alternatives, 
LTACH is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
an adult prophylaxis (D1110), and an intraoral first radiographic image (D0220) provided on May 2, 2023.  
 
You asked the Plan to pay more for the dental services. You say that you have an annual out-of-network and in-
network benefits for $2,000. You also say your responsibility should be $0 cost share. 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 a periodic oral evaluation (D0120), 
bitewings (D0274), an adult prophylaxis (D1110), and an intraoral first radiographic image (D0220) provided 
on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) for tooth #31 and a retainer crown (D6740) 
for tooth #32 provided on June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking the Plan to reprocess the claim 
for payment. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a pontic (D6245) for tooth #30 and a retainer crown (D6740) for tooth #29 on June 9, 
2023; therefore, the enrollees benefit for the requested items or services was exhausted on the date of service 
of June 9, 2023. Therefore, we decided that the Plan does not have to pay for a pontic (D6245) for tooth #31 
and a retainer crown (D6740) for tooth #32 provided on June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT Peripheral Nerve Stimulation (PNS) 
system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. The Plan denied your request. The Plan says there 
are not enough studies to show that SPRINT PNS is better than other regular treatment for chronic pain. 
 
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 the SPRINT PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this service is the subject of ongoing clinical trials and is considered an 
experimental procedure. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SPRINT PNS system. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT Peripheral Nerve Stimulation (PNS) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM sensor kit. 
 
You asked the Plan to pre-approve a CGM sensor kit. You say that the requested items are a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies have not 
been met. 
 
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 you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a CGM sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre CGM sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration of 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not reflect a need for services at the LTACH that are not available at 
the current acute care hospital. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need this for your impaired balance and 
strength. The Plan denied your request. The Plan says you can be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the enrollee's medical condition does not allow them 
to check their sugar levels using the finger pricking method. The Plan denied your request. The Plan says the 
Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the enrollee has diabetes mellitus. The 
enrollees treating practitioner did not conclude that the enrollee or their caregiver has sufficient training using 
the CGM prescribed, as evidenced by providing a prescription. The requested CGM is not being prescribed in 
accordance with its Food and Drug Administration (FDA) indications for use. The enrollee is not insulin 
treated or have a history of problematic hypoglycemia. The documentation provided does not support that 
within 6 months prior to ordering the CGM, the treating physician had an in-person or Medicare-approved 
telehealth visit with the enrollee to evaluate their diabetes control and determine whether criteria for coverage 
are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 20, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary as your blood sugar had dropped. 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 20, 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 response and treatment without 
transport services received on July 20, 2023.