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

 
We decided that the Plan does not have to pay for amalgam- two surfaces (D2150) provided on August 16, 
2023. 
 
You asked the Plan to pay for amalgam- two surfaces. 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 pay for amalgam- 
two surfaces (D2150) provided on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve medical nutrition therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that no one informed you and you were unaware of 
the 1-year limitation, and you assumed it was every 6 months. The Plan denied your request. The Plan says 
your benefit for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a periodic oral evaluation (D0120) and a cleaning (D1110) on February 6, 2023; 
therefore, your benefit for the requested items or services was exhausted on the date of service of February 6, 
2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a 
cleaning (D1110) provided on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on July 5, 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 a crown 
(D2740) provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 9, 
2023. 
 
You asked the Plan to pay for the dental service. You say that it is your understanding you are allowed 2 
regular and 2 deep cleanings every year. 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 the Plan paid for a cleaning (D1110) on March 14, 2023; therefore, your benefit for the requested item 
or service was exhausted on the date of service of March 14, 2023. Therefore, we decided that the Plan does 
not have to pay for the periodontal maintenance (D4910) provided on May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 51 additional one-way trips. 
 
You asked the Plan to pre-approve 51 additional one-way trips. You say that you need reliable transportation to 
make it to your appointments, as you have no other means of transportation. The Plan denied your request. The 
Plan says this benefit has been exhausted. 
 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 one-way 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 51 additional one-way trips.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a ganglion impar block. 
 
You asked the Plan to pre-approve a ganglion impar block. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 a ganglion impar block. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is standard of care for coccydynia. The request is medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ganglion impar block have been met. Therefore, we decided that the Plan has 
to pre-approve a ganglion impar block.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the endodontic therapy 
(D3320) for tooth #28 provided on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan told you that the dental services would 
be covered, and the bill should not be your responsibility. The Plan denied your request. The Plan says your 
annual maximum benefit for the year has already been exhausted. Also, it was verified prior to the date of 
service you did not want to review your benefits and only asked for an in-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $59 for dental services on April 4, 2023. On May 23, 2023, the Plan paid $582.50 for 
dental services. On June 15, 2023, the Plan paid $358.50 for dental services. For the year of 2023 the Plan paid 
$1,000 ($59 paid + $582.50 paid + $358.50 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of June 15, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) and the endodontic therapy (D3320) for 
tooth #28 provided on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the acupuncture services, the infrared 
therapy, and the manual therapy techniques provided on June 13, 2023, to August 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit, the acupuncture services, the infrared therapy, and the manual 
therapy techniques. You say that you were told that the acupuncture services were 100% covered. The Plan 
denied your request. The Plan says that the services are available in network. 
 
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 the office visit, the acupuncture services, the 
infrared therapy, and the manual therapy techniques provided on June 13, 2023, to August 10, 2023, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were in pain, and you had to see multiple 
providers so they could do a root canal. 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 the Plan paid for a limited oral evaluation (D0140) on August 7, 2023, and August 14, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of August 14, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #3 and #4. 
 
You asked the Plan to pre-approve the dental services. You say that you need implants and you read that 
implants are covered at 50% and they are medically necessary. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because tooth Implants and transplants including select 
crowns and any associated care for implant placement 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 
surgical placement of implant body (D6010) for tooth #3 and #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary because 
the enrollee has failed conservative treatment and they will provide cushioning and support to the enrollee 
during everyday activities. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.   
 
  Records show that the enrollee does not suffer from diabetic foot disease, and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage 
of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6061). 
 
You asked the Plan to pre-approve abutment supported porcelain fused to metal crown. 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 
abutment supported porcelain fused to metal crown (D6061).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics provided by a non-Medicare certified 
provider on July 25, 2023.  
 
You asked the Plan to pre-approve foot orthotics. You say that the Plan told you that the item would be covered 
at 80% and that your provider is an in-network provider. The Plan denied your request. The Plan says this item 
is not a covered benefit, and the rendering provider is a non-Medicare certified provider. 
 
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. The rules also say 
that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.   
 
  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. 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 pre-approve foot orthotics provided by 
a non-Medicare certified provider on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
image (D0220), a cleaning (D1110), and a crown (D2740) for tooth #5 provided by an out-of-network provider 
on June 27, 2023, and July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider said the Plan will pay for the dental 
services and they would cover $2,000. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the intraoral radiographic image (D0220), a cleaning (D1110), 
and a crown (D2740) for tooth #5 provided by an out-of-network provider on June 27, 2023, and July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported removable denture (D6111) provided on 
June 6, 2023. 
 
You asked the Plan to pay for implant supported removable denture. 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 pay for implant 
supported removable denture (D6111) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and pontic (D2950, D6245) provided 
on July 10, 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 core 
buildup services and pontic (D2950, D6245) provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute, A2001- InnovaMatrix AC. 
 
You asked the Plan to pre-approve skin substitute, A2001- InnovaMatrix AC. You say that the requested skin 
substitute is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
skin substitute, A2001- InnovaMatrix AC is not medically necessary. 
 
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 skin substitute, A2001- InnovaMatrix 
AC. Our reviewer says that the requested skin substitute, A2001- InnovaMatrix AC is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the medical documentation supports 
that this injured enrollee underwent an incision and drainage of the right foot with resection of the third and 
fourth metatarsal heads on October 13, 2023. This is considered a fresh new wound as of the incision and drainage and debridement with removal of infected bone and soft tissue. Follow-up treatment has been 
recommended including wound debridement, wound vacuum-assisted closure (VAC), and antibiotic therapy. In 
this particular case little time has elapsed between surgical excision of infected bone and soft tissue to the right 
foot, and a request for advanced wound care and dressing application including InnovaMatrix AC. Essentially, 
these advanced wound care dressings are generally reserved for nonhealing ulcerations. It is unclear that this 
enrollees right foot wound is a nonhealing diabetic foot ulceration at this point. The medical documentation 
also supports the absence of lower extremity vascular disease with what appear to be relatively normal 
segmental pressures.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute, A2001- InnovaMatrix AC have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skin substitute, A2001- InnovaMatrix AC.