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

 
We decided that the Plan does not have to pre-approve the mouth guard. 
 
You asked the Plan to pre-approve the mouth guard. You say that it is painful to open and close your mouth. 
You say that it is medically necessary to get a mouth guard. The Plan denied your request. The Plan says the 
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 the 
mouth guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies and skin seal protect moisturizer.
You asked the Plan to pre-approve incontinence supplies and skin seal protect moisturizer (A6250). You say
that because of a medical condition you need the supplies daily. The Plan denied your request. The Plan says
these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable. Medicare rules also state that skin sealants do not meet
the definition of a dressing.
While incontinence supplies and skin seal protect may be appropriate in this case, neither the Plan nor
Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve
incontinence supplies and skin seal protect moisturizer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for a consultation.
You asked the Plan to pre-approve the physician's services for a consultation. The Plan denied your request.
The Plan says the enrollee must receive care from in-network providers with the exception of emergency or
urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an
in-network provider, which requires prior authorization from the plan.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services for a consultation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture. 
 
You asked the Plan to pre-approve the complete upper denture. You say that you never received any dentures. 
The Plan denied your request. The Plan says the service is limited to once every 5 years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one set of partial, full or immediate dentures every 5 years. The Plan paid for a complete upper denture on 
March 8, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve 
the complete upper denture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardiac Computed Tomography (CT) with calcium 
scoring (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan and calcium scoring is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
CT scan and calcium scoring is not medically necessary. Our physician reviewer found given only mild 
elevation of the enrollee's LDL with no clear intolerance of pravastatin and in the absence of symptomatic 
disease, a repeat calcium score would not be medically necessary as it had already been done only one year ago 
(and twice in the last 3 years) to guide management of his risk factors. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cardiac Computed Tomography (CT) with calcium scoring (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit, a duplex scan and injections for varicose 
veins. 
 
You asked the Plan to pre-approve the office visit, a duplex scan and injections for varicose veins. The Plan 
denied your request. The Plan says you must receive care from in-network providers with the exception of 
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit, a duplex scan and injections for varicose veins.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the removal and replacement of an IUD (58300 and 
J7298) provided on January 16, 2020. 
 
You asked the Plan to hold you harmless for the IUD. You say that you would like reconsideration because you 
do not use Mirena for contraception. The Plan denied your request. The Plan says that this request is not a 
covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the IUD by a contract provider. The file does not show that the Plan provided notice that 
the IUD would not be covered. Under Medicare rules, this means the IUD is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for the removal and replacement of an IUD 
(58300 and J7298) provided on January 16, 2020.  
 
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 pre-approve an exposure of an unerupted tooth (D7280), placement
of device to facilitate eruption of impacted tooth (D7283), first 15 minutes of deep sedation/general anesthesia
(D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223).
You asked the Plan to pre-approve the exposure of an unerupted tooth, placement of device to facilitate
eruption of impacted tooth, deep sedation/general anesthesia services. You say that you need this procedure
because you are in a lot of pain. The Plan denied your request. The Plan says these services are not covered by
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 Plan's 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 an
exposure of an unerupted tooth (D7280), placement of device to facilitate eruption of impacted tooth (D7283),
first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of
deep sedation/general anesthesia (D9223).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan, thorax; without contrast material on January 9, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were advised by customer service the claim was paid as out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a CT scan, thorax; without contrast material on January 9, 2020. The claim was processed as in-network. You are asked to pay a $130 copayment for the CT scan. Your EOC states that enrollees must pay a $130.00 copay for covered diagnostic radiology services in a provider's office or freestanding radiology center. 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 CT scan, thorax; without contrast material on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brand specific portable oxygen concentrator. 
 
You asked the Plan to pre-approve a brand specific portable oxygen concentrator. You say that your current 
portable oxygen concentrator is too heavy for you when doing chores outside of the house or going to the store. 
The Plan denied your request. The Plan says your current portable oxygen concentrator is meeting your in 
home oxygen needs and the suppliers say it is the lightest available. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. The rules say Medicare covers DME only when it is 
reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is 
not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. There is no documentation that your current portable oxygen 
concentrator is not meeting your in home needs. Therefore, we decided that the Plan does not have to pre-
approve a brand specific portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates the enrollee is not testing his blood glucose four or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) and supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95827) provided on July 17, 2018.
You asked the Plan to pay for the electroencephalogram. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the medical records submitted do not
indicate that electroencephalogram (EEG); all night recording was performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95827 is electroencephalogram (EEG); all night
recording.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the electroencephalogram. Our reviewer says that CPT code
95827 does not meet criteria for billing or reimbursement consideration. Our reviewer found Medicare does not
have specific guidelines for 95827 to include the time required to record an all night EEG. Per documentation
EEG was recorded for 5 hours and 45 minutes.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the electroencephalogram have not been met. Therefore, we decided that the
Plan does not have to pay for an electroencephalogram (95827) provided on July 17, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system. 
 
You asked the Plan to pre-approve a portable gaseous oxygen system. You say that the hospital prescribed the 
use of home oxygen. The Plan denied your request. The Plan says there are no blood gas studies or oxygen 
saturations noted in the submitted clinical documentation. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
We looked at the file and Medicare rules. There is no documentation of blood gas levels. Based on this 
information, we decided that Medicare rules for coverage of a portable gaseous oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a portable gaseous oxygen system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on March 2,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare says non-urgent services should be from network providers who are contracted with
the healthplan and listed in the Provider Directory.
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 has network providers
available who can provide 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 office visit services provided to the enrollee on
March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's current needs are being met in the acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (CPT 37606) provided to the enrollee on 
March 30, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records indicate that the claim was billed with an incorrect procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37606 is "Ligation; internal or common carotid artery, 
with gradual occlusion, as with Selverstone or Crutchfield clamp." 
 
We asked our coding 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the records 
submitted indicate that the service provided was Healthcare Common Procedure Coding System (HCPCS) code 
K0606.  The documentation provided does not include documentation of a 37606 - Ligation; internal or 
common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp being provided on 
March 30, 2020, therefore, this service cannot be verified. 
 
We looked at this coder'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 pay for physician services (CPT 37606) provided to the enrollee on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on July 1, 2019. 
 
You asked the Plan to pay for the self-administered drug. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 the self-administered drug 
provided on July 1, 2019.
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 requested orthotics were recommended by 
your doctor to assist with your balance. You say that you do not have a kneecap in your left leg and the 
orthotics would help with your balance and prevent a possible fall. You stated that you have had back surgery 
and the orthotics were suggested for you to improve your stability. You asked the Plan to reconsider their 
decision. 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 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 foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air conditioner (S5165). 
 
You asked the Plan to pre-approve an air conditioner. You say that you have breathing problems and a heart 
condition and you really need a bigger AC. The Plan denied your request. The Plan says this item is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an air conditioner (S5165).