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

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a 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 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. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor 
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on April 5, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as you 
did not submit valid proof of payment for the 2023 calendar year.  
  
 
 
 
 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because you did not submit valid proof of 
payment for this service for the 2023 calendar year wellness allowance benefit. Therefore, we decided that the 
Plan does not have to issue reimbursement for the health club membership (S9970) purchased on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided on May 26, 
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 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 April 21, 2020. 
Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided on 
May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
18, 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 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 September 20, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210, prophylaxis - adult (D1110), and comprehensive oral evaluation - new or established patient (D0150) 
provided on September 21, 2022. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images,  prophylaxis and the 
comprehensive oral evaluation. You say that this provider was in-network prior to getting these services. 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 the intraoral - complete series of radiographic images (D0210, prophylaxis - adult (D1110), and 
comprehensive oral evaluation - new or established patient (D0150) provided on September 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit performed 
at an outpatient hospital facility provided on April 03, 2023, to April 14, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit performed at an outpatient 
hospital facility. You say that you believe the copayment applied is incorrect. 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 $30 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30 copayment for each physical therapy (PT) visit performed at an outpatient 
hospital facility. This item/service falls within the outpatient rehabilitation services 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. The total copayment you 
owe is $180 for PT services provided at an outpatient hospital facility ($30 per visit x 6 visits = $180). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
performed at an outpatient hospital facility provided on April 03, 2023, to April 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from June 5, 2023, to June 
7, 2023. 
 
You asked the Plan to pay for the medication. You say that the charges are not your responsibility. 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 pay for self-administered drugs provided 
from June 5, 2023, to June 7, 2023.  
 
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: 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 you need help with your diabetes. 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 additional information from your physician 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 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 pay for an intraoral - comprehensive series of x-rays (D0210) 
provided on May 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are getting a lower jar partial. You also say 
you need this teeth numbers 1 to 32 radiographic images to complete your partial denture. 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 January 6, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - comprehensive series of x-rays 
(D0210) provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on May 9, 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 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 an 
endosteal implant (D6010) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain fused to noble metal tooth #'s 6 
and 8 (D6752), core buildup, including any pins when required (D2950), pontic - porcelain fused to noble 
metal (D6242), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), 
prefabricated post and core in addition to crown (D2954), intraoral - periapical first radiographic image 
(D0220), and amalgam - one surface, primary or permanent (D2140) provided on January 10, 2023, and 
February 15, 2023. 
 
 
 You asked the Plan to pay for the dental services. You say that the enrollee was on vacation and broke tooth #7. 
You also say that the tooth was non-restorable and required an extraction which the submitted doctor's notes 
explain. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by the enrollees supplemental benefits. The Plan also says that the attending 
dentist did not state that this was an emergency on the claim. 
 
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. The Plan has directed the dental program provider 
to pay the enrollee $100.00 emergency claim. Therefore, we decided that the Plan does not have to pay for a 
retainer crown - porcelain fused to noble metal tooth #'s 6 and 8 (D6752), core buildup, including any pins 
when required (D2950), pontic - porcelain fused to noble metal (D6242), extraction, erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140), prefabricated post and core in addition to crown (D2954), 
intraoral - periapical first radiographic image (D0220), and amalgam - one surface, primary or permanent 
(D2140) provided on January 10, 2023, and February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that your first service was done on February 21, 
2023 and the code is D4910 for periodontal. You also say that the next cleaning in June was code D1110 and 
the provider said it was different from the first as this was a regular cleaning. The Plan denied your request. 
The Plan says your benefit for the requested 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 services was exhausted on date of service February 21, 2023. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on June 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) services (87637, 99283) provided on 
May 18, 2023. 
 
You asked the Plan to pay for the ER 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 (87637, 
99283) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided June 1, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you only have used your dental twice. 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 November 20, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on May 
16, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that you received a letter 
stating you should not be responsible for the charges because they are a participating provider. The Plan denied 
your request. The Plan says the services are non-covered based on your EOC. 
 
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 these services when it is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. Based on this information, we decided that the Plan's 
rules for coverage of a determination of refractive state (92015) have not been met. Therefore, we decided that 
the Plan does not have to pay for a determination of refractive state (92015) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on May 25, 2023. 
 
You asked the Plan to pay for an office visit (99204). You say that you went to this provider to have a routine 
eye examination to see how your eyes look. You also say that the provider only did a routine eye examination, 
and nothing else. 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 (99204) 
provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraoral - periapical first radiographic image 
(D0220), core buildup (D2950) and local anesthesia in conjunction with operative or surgical procedures 
(D9215). 
 
You asked the Plan to pre-approve the dental services. You say that the doctor requested the x-rays done. You 
also say that the core buildup is something that assists in the crown procedure. 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 an intraoral - periapical first radiographic image (D0220) was exhausted on date of 
service June 22, 2023. Also, though the Plan offers a dental benefit in excess of Medicare coverage, the core 
buildup (D2950) and local anesthesia in conjunction with operative or surgical procedures (D9215) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
intraoral - periapical first radiographic image (D0220), core buildup (D2950) and local anesthesia in 
conjunction with operative or surgical procedures (D9215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #5, 13, and 15 (D2740) and core build 
up on tooth #5, 13, and 15 (D2950). 
 
You asked the Plan to pre-approve the crowns and core build up. You say that you are requesting 
reconsideration of the denied services based on medical necessity. The Plan denied your request. The Plan says 
for these services to be approved more than half of your tooth must be damaged due to decay or injury. 
 
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 Plan covers the crowns 
and core build up when the services are medically necessary and reasonable.  
 
 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 crowns and core build up. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found that they were 
unable to determine that procedures D2950 and D2740 for teeth numbers 5,13, and 15 are medically reasonable 
or necessary due to a lack of information. The panoramic x-ray dated July 27, 2023, was reviewed. From the x-
ray, it was seen that there are fillings in tooth #5,13, and 15. Only one of the fillings can be seen. The review 
was only able to assess the length and depth of the fillings, but not the width as there were no photos included 
with the clinical documentation, and no clinical notes documenting the size of the filling. Based on the current 
records included, the procedures requested are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and core build up have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown on tooth #5, 13, and 15 (D2740) and core build up on tooth #5, 13, 
and 15 (D2950).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on April 19, 2023. 
 
You asked the Plan to waive the copayment for  ER visit. You say that you were told to go to the ER by your 
doctor but at the ER they told you there was no reason to come in, so you believe this should be covered. 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 $110 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay $110 copayment for ER visit. This item/service falls within the emergency 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 ER visit provided on April 19, 
2023.