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

 
We decided that the Plan does not have to pre-approve two series of hearing tests, two office consultations and 
treatment, a hearing aid examination, and two digital hearing aids with a non-network provider. 
 
You asked the Plan to pre-approve two series of hearing tests, two office consultations and treatment, a hearing 
aid examination, and two digital hearing aids with a non-network provider. You say that the services and 
hearing aids from this provider cost less than one-half of the Plan provider prices. The Plan denied your 
request. The Plan says this facility is a non-network provider for this Plan. The Plan also says that there are in-
network providers available. 
 
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. The Plan pays for 
hearing aids only when the services and items are obtained through a Plan selected provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of two series of hearing tests, two office consultations and treatment, a hearing aid examination, and 
two digital hearing aids with a non-network provider have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two series of hearing tests, two office consultations and treatment, a hearing aid 
examination, and two digital hearing aids with a non-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) services (73610, 87637, 99284) 
provided on May 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering 
provider is not enrolled with Medicare. 
 
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 emergency room (ER) services (73610, 
87637, 99284) provided on May 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 24, 2023, to April 1, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not believe you 
owe the copayment for the inpatient stay. 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 $300 
copayment per day for days 1-5 and $0 copayment per day for additional days for Medicare-covered inpatient 
hospital stays. 
 
You have been asked to pay a total of $1,500 for the inpatient hospital stay ($300/day x 5 days = $1,500). The 
inpatient hospital stay falls within the inpatient hospital 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 copayment for the inpatient hospital stay provided from March 24, 2023, to April 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), deep sedation/general anesthesia  first 15 minutes  (D9222), 
and each subsequent 15 minute increment  (D9223). 
 
You asked the Plan to pre-approve the therapeutic parenteral drugs and sedation/general anesthesia. You say 
that you have 6 teeth that need to be surgically removed and then have the bone sawed down. You also say that 
you are prediabetic, 70  years old and this is more than what you can handle if you do not have the anesthesia. 
The Plan denied your request. The Plan says these services are not covered in your 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 
therapeutic parenteral drugs, two or more administrations, different medications (D9612), deep 
sedation/general anesthesia  first 15 minutes  (D9222), and each subsequent 15 minute increment  (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on April 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 core 
buildup services (D2950) provided on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver and sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 receiver and sensor. The Plan denied your request. The Plan 
says only the preferred brand products listed in the EOC are covered. The Plan also says in order to get the 
Dexcom Sensor you need to document that the enrollee has tried and failed the Freestyle Libre or why they 
cannot use it. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G7 received and sensor. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 receiver and sensor.
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 requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary 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. Specifically, the request for information 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213). 
 
You asked the Plan to pre-approve the partial denture. The Plan denied your request. The Plan says your 
benefit for the maxillary partial denture 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 October 14, 2019. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement hearing aid (V5050). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 this item have not been met. Specifically, a replacement hearing aid is not a covered benefit. 
Therefore, we decided that the Plan does not have to pre-approve a replacement hearing aid (V5050).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision attachment (D6192). 
 
You asked the Plan to pre-approve semi-precision attachment. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
semi-precision attachment (D6192).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown (D2740), a partial 
lower denture (D5214), and a core buildup, including any pins when required (D2950). 
 
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 the enrollees benefit for the requested dental 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 the enrollees benefit for the requested items was exhausted on date of service April 11, 2023.   
 
 
 
 
 
Specifically, the Plans contract states that there is a $3,500 maximum allowance every year for dental services. 
The Plan issued payment in the amount of $3,500 for dental services provided to the enrollee for the 2023 
calendar year. Therefore, the enrollee has exhausted the allowable benefit for the dental items requested in this 
case. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown 
(D2740), a partial lower denture (D5214), and a core buildup, including any pins when required (D2950).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 48 additional trips for routine transportation. 
 
You asked the Plan to pre-approve the 48 additional trips. You say that you need transportation more 
frequently due to your disability. The Plan denied your request. The Plan says your request exceeds your yearly 
benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 48 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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 requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture maxillary (D5110). 
 
You asked the Plan to pre-approve complete denture maxillary. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete denture maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing-four or more teeth per quadrant (D4341 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on all 
4 quadrants, the localized delivery of antimicrobial agents (D4381) for tooth #2, #4, #5, #11, #12, #13, #16, 
#18, #19, #20, #21, #22, #27, #28, #29, and #31, a partial upper denture (D5213), and the surgical removal of 
erupted tooth (D7210) for tooth #16. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the periodontal scaling and root planing, the localized delivery of antimicrobial agents, a partial upper 
denture, and the surgical removal of erupted tooth are not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4341) on all 4 quadrants, the localized delivery of antimicrobial agents 
(D4381) for tooth #2, #4, #5, #11, #12, #13, #16, #18, #19, #20, #21, #22, #27, #28, #29, and #31, a partial 
upper denture (D5213), and the surgical removal of erupted tooth (D7210) for tooth #16.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered. 
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 dental services provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the frequency exception for an early benefit 
reinstatement for new eyewear. 
 
You asked the Plan to pre-approve the frequency exception for an early benefit reinstatement for new eyewear. 
You say that want the routine vision allowance to be refreshed early because you lost the glasses you got in 
May and cannot see. The Plan denied your request. The Plan says routine eyewear includes the lenses and one 
pair of eyeglass frames or contact lenses every year. The Plan also says that replacement due to loss, damage, 
style or stolen (glasses or contact lenses) are not covered. 
 
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 routine eyewear each year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $575 allowance toward the cost of 
routine eye wear every year. The Plan rules say that routine eyewear includes the lenses, and one pair of 
eyeglass frames every year. This benefit was exhausted May 3, 2023. Based on this information, we decided 
that the Plan's rules for coverage of frequency exception for an early benefit reinstatement for new eyewear 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the frequency exception 
for an early benefit reinstatement for new eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation for an 
upcoming procedure. 
 
  You asked the Plan to pre-approve additional mileage for routine transportation for an upcoming procedure. 
You say that you need the extra miles because your primary care provider referred you for a procedure, and this 
is the only provider that can see you soon. The Plan denied your request. The Plan says the requested 
transportation was for 64 miles, which exceeds the limit of this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles per each one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation for an 
upcoming procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival flap procedure, including root planing - one 
to three contiguous teeth or tooth bounded spaces per quadrant (D4241). 
 
You asked the Plan to pre-approve the gingival flap procedure. You say that you require this service because 
you have gum problems and the doctor needs to clean the infection that the tooth has. You also say that they 
have tried different processes, but you continue to have discomfort. The Plan denied your request. The Plan 
says this procedure is not covered in your dental coverage. 
 
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 
gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per 
quadrant (D4241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you receive eye injections and you don't 
feel it's safe to drive in your condition. You also say that you need the additional trips for medical appointments 
that are not near your home. The Plan denied your request.  The Plan says once you have exhausted those 20 one-way trips, you are not eligible for any additional 
transportation trips until the beginning of the next year, which would be January 1, 2024. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).