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

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on January 
25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was a surgical procedure and should be 
covered under your medical benefit. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental 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. Additionally, this procedure is not one of the limited Medicare covered 
dental procedures covered under your medical benefit. Therefore, we decided that the Plan does not have to pay 
for the clinical crown lengthening (D4249) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you never received the dentures back in 
2022 and so there should be no frequency limit on the 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 that the Plan paid for a partial upper denture (D5213) on November 10, 2022; therefore, your benefit for 
the requested item or service was exhausted on the date of service of November 10, 2022. Therefore, we 
decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgeryone to three contiguous teeth or tooth 
bounded spaces per quadrant (D4261) provided on November 15, 2022. 
 
You asked the Plan to pay 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 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 service provided is not among 
those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pay for the osseous surgeryone to three contiguous teeth 
or tooth bounded spaces per quadrant (D4261) provided on November 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 5, 2023, to 
February 3, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on January 5, 2023, 
to February 3, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee is exhibiting behavioral changes 
such as agitation and aggression. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is suspected of having a 
neurodegenerative disease. However, they are not noted to meet criteria for either AD or FTD at this time. 
Alternative causes have not been ruled out. Given that the initial requirements of the NCD for coverage of this 
service have not been met, this service would not be eligible for coverage at this time. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam, the fundus 
photography, the updated current medications provided on January 25, 2023. 
 
You asked the Plan to waive the copayment for the vision items. You say that this was a routine eye 
examination, and you should not be charged a copayment. 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 the Medicare-covered vision services at an in-network specialist's office.  
 
 You have been asked to pay a $30 copayment for the vision items. The record shows a diagnosis of other 
retinal disorders which makes the services medical in nature. These items fall within the vision 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 medical eye exam, the fundus photography, 
the updated current medications provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 12, 2023, through January 30, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on January 12, 2023, through January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites-two surfaces, posterior  
(D2392 x 2) provided on November 18, 2022. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollees benefit for the dental items 
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 that the enrollees benefit for the dental items provided was exhausted on date of service April 15, 2023.  
  
 
 
 
Specifically, the Plans contract states that two restorations (fillings) are covered per calendar year. The 
enrollee previously received two dental fillings on January 31, 2023 and April 15, 2023 accordingly, which 
were paid for by the Plan. Therefore, the enrollee has exhausted the allowable benefit for the dental items 
provided in this case. Therefore, we decided that the Plan does not have to pay for the resin-based composites- 
two surfaces, posterior (D2392 x 2) provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a cleaning (D1110), the 
resin-based composites (D2332, D2335, D2393, and D2394) for tooth #8, #9, #10, #13, #15, and #20 provided 
by an out-of-network provider on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that there are no in-network providers near you that 
will accept new patients. 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. Also, it was verified that there 
are multiple in-network providers that are within your service area that are accepting new patients. 
 
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), a cleaning (D1110), the resin-based composites (D2332, D2335, 
D2393, and D2394) for tooth #8, #9, #10, #13, #15, and #20 provided by an out-of-network provider on 
January 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not understand why the IRF request keeps 
getting denied. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on March 13, 2023.  
You asked the Plan to pay for the vision supply. You say that you were advised that you had a one-year 
replacement policy but were never told that there would be a $25 charge. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
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 says this is not a covered benefit. 
 
We looked at the file and the Plan's rules. Specifically, the service is not listed as a covered benefit. Based on 
this information, we decided that the Plan's rules for coverage of the vision supply have not been met. 
Therefore, we decided that the Plan does not have to pay for the vision supply provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the scaling 
in moderate or severe gingival inflammation (D4346) provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing because you believed that the 
dentist was in-network. The Plan denied your request. The Plan says your benefit for the comprehensive oral 
evaluation has already been exhausted. Also, the denial of payment for the scaling in moderate or severe 
gingival inflammation is correct, because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on the date of service of March 22, 
2022. The scaling in moderate or severe gingival inflammation is not covered under the Plans dental benefit. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the scaling in moderate or severe gingival inflammation (D4346) provided on September 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 17, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not under hospice care on 
the date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the comprehensive oral evaluation (D0150), 
intraoral-complete series of radiographic images (D0210), dental cleaning (D1110), and the topical application 
of fluoride varnish (D1206) provided on March 20, 2023. 
 
You asked the Plan to issue reimbursement for the dental services. You say that you are requesting are 
reconsideration of the Plan's denial for payment. 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 dental services from an out-of-network provider.  
  
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to issue reimbursement for the comprehensive oral evaluation (D0150), intraoral-complete series of 
radiographic images (D0210), dental cleaning (D1110), and the topical application of fluoride varnish (D1206) 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on  
March 15, 2023. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office or other outpatient visit provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0210 and D0150) on March 1, 2023. 
 
You asked the Plan to pay for the dental services (D0210 and D0150). You say that you would like to request 
reconsideration of the denied claim. 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 June 21, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services (D0210 and D0150) on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-implanted continuous glucose monitor (CGM) 
sensors (A4239) provided on February 13, 2023. 
 
You asked the Plan to pay for the CGM sensors. You say that the item should be covered. The Plan denied your 
request. The Plan says claims must be filed with enrollee's primary insurance first and an explanation of 
benefits must be submitted. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan has 
been in direct communication with the provider indicating the primary insurance needs to be billed first and an 
explanation of benefits must be submitted.. As the secondary insurer, the Plan cannot be held responsible for 
the CGM sensors until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for the non-implanted continuous glucose monitor (CGM) sensors (A4239) 
provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0675). 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says a PCD that provides intermittent limb compression for the purpose 
of prevention of venous thromboembolism is a preventive service 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675).