Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says the enrollee does not 
require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. 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 14 day continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022 to 
August 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was received on 
September 9, 2022 and the medical records submitted justify the medical necessity. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 1, 2022 to 
August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D2950 and D3330. You say that the 
dental office/doctor were and still are in your network, so it should have been processed as in network. The 
Plan denied your request. The Plan says your benefit for the requested services $1,000 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. The record 
shows your benefit for the requested services was exhausted on date of service November 14, 2022. The claim 
processed correctly as you had maxed out your dental reimbursement on this date of service. Therefore, we 
decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve D6056. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service 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, 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 
prefabricated abutment (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you say that your provider said it is in the 
best interest of your health to have the requested services. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. This benefit includes coverage 
for the requested D7210, but only when they are received from an in-network provider. D0160, D0367, D6118, 
D9944, D9215, D6010, D6191, D6192 and D6104 are not covered under the Plans dental benefits. 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested D7210 is not covered under this benefit when received from an 
out-of-network provider. Also, the requested D0160, D0367, D6118, D9944, D9215, D6010, D6191, D6192 
and D6104 are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310) and a complete mandibular 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial for in-home 
dental services. The Plan denied your request. The Plan says dental services from an out-of-network provider 
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. 
 
 
 
 You are requesting 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 pre-approve a 
consultation (D9310) and a complete mandibular denture (D5120).
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 CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that your legs are swollen. The Plan 
denied your request. The Plan says this is not a surgical dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531 and 
foot orthotics. 
 
You asked the Plan to pre-approve the compression stockings and foot orthotics. You say that you are a pre-
diabetic, and the requested items are medically necessary. The Plan denied your request. The Plan says the 
requested items are non-covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
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. 
 
Although the compression stockings may be appropriate, it does not fall into a covered benefit category and 
cannot be paid for by Medicare or the Plan. 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 compression stockings identified with code A6531 and foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and annual depression screening provided on 
January 04, 2023. 
 
You asked the Plan to pay for an office visit and annual depression screening. You say that this is your primary 
care provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
annual depression screening provided on January 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect (0012M) provided August 11, 2022. 
 
You asked the Plan to pay for the Cxbladder Detect. You say that the evidence supporting the use of Cxbladder 
Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says the CX Bladder panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder Detect have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect (0012M) provided August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on November 28, 
2022. 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the criteria for approval have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM) on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental fillings (D2393, D2391, D2331). 
 
You asked the Plan to pre-approve 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 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 pre-approve 
dental fillings (D2393, D2391, D2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontin and retainer crown (D6740, D6245). 
 
You asked the Plan to pre-approve 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 pontic denied correctly as they do not 
fall within your dental benefits. Coverage for the retainer crown denied correctly as you do not meet the 
clinical requirements to be approved. 
 
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, pontics are not among those covered 
under this benefit. The record also indicates that you do not meet the clinical requirements to be approved for a 
retainer crown. Therefore, we decided that the Plan does not have to pre-approve a pontic and retainer crown 
(D6740, D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete upper denture (D5110) and a 
complete lower denture (D5120) and to pay for a consultation (D9310) provided on August 24, 2022, and 
September 21, 2022. 
 
You asked the Plan to waive the coinsurance and to pay for the dental services. You say that you waited 6 
months for your dentures, and they did not fit, and you would like to get a new pair of dentures. The Plan 
denied your request. The Plan says the denial of payment for the consultation is correct because it is not 
covered by the Plan. Also, the proper cost share was applied. 
 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 consultation is not among those 
covered under this benefit. The total allowed amount for the complete upper denture was $778.52 with a 
coinsurance amount of $311.40 ($778.52 allowed x 40% coinsurance). The total allowed amount for the 
complete lower denture was $808.12 with a coinsurance amount of $323.24 ($808.12 allowed x 40% 
coinsurance). You have been asked to pay a 40% coinsurance for the dentures. 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 a complete upper denture (D5110) and a complete lower denture 
(D5120) and to pay for a consultation (D9310) provided on August 24, 2022, and September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access 
(D3331), surgical procedure for isolation of tooth with rubber dam (D3910) and intraorifice barrier (D3911). 
 
You asked the Plan to pre-approve dental services. You say that you do not understand why the services are 
being denied. The Plan denied your request. The Plan says this service is 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. Treatment of root canal 
obstruction; non-surgical access (D3331), surgical procedure for isolation of tooth with rubber dam (D3910) 
and intraorifice barrier (D3911) are not covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D3331, D3910 and 
D3911 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve treatment of root canal obstruction; non-surgical access (D3331), surgical procedure for isolation 
of tooth with rubber dam (D3910) and intraorifice barrier (D3911).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950). 
 
You asked the Plan to pre-approve 2950. You say that you need this dental work. The Plan denied your request. 
The Plan says D2950 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, 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 
core build-up (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (20930, 22558, 22612, 22840, 22853, 
63048). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has lumbar radiculopathy with 
worsening symptoms. The Plan denied your request. The Plan says the fusion surgery is not medically 
necessary without fracture, pars defect, or unstable spondylolisthesis, and is not a covered benefit as planned 
and requested. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not show any evidence of spinal instability on imaging studies. Fusion is not needed.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery (20930, 22558, 22612, 22840, 22853, 63048).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement, mitral valve, with cardiopulmonary bypass 
(33430) provided March 9, 2022. 
 You asked the Plan to pay for the surgical procedure. You say that please review and reprocess the claim. The 
Plan denied your request. The Plan says the procedure is not eligible for a co-surgeon. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the surgical procedure have been met. 
Additional medical records were required from the provider. The records show that the Plan made multiple 
attempts to obtain the needed records from the provider without success. Therefore, we decided that the Plan 
does not have to pay for the replacement, mitral valve, with cardiopulmonary bypass (33430) provided March 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 7, 2022, to April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that this 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 April 7, 2022, to April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) for tooth #12 provided 
on August 12, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary to get the dental 
service done because you had a tooth that was erupted, and it should be paid for out of medical necessity. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because dental care or 
procedures that are not covered by Medicare are also not covered by the 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 the bone replacement graft 
(D7953) for tooth #12 provided on August 12, 2022.