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

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and complete 
lower denture (D5120). 
 
You asked the Plan to pre-approve the complete upper denture and complete lower denture. You say that you 
need new dentures. The Plan denied your request. The Plan says you have exhausted your benefit for these 
services. 
 
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. The Plan covers the complete 
upper denture and complete lower denture once every 60 months.  
 
We looked at the file and Medicare rules. The file indicates that you received these services last in July 2020. 
As a result, you have exhausted your coverage limit for the services requested. Based on this information, we 
decided that the Plan's rules for coverage of the complete upper denture and complete lower denture have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture 
(D5110) and complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental surgery procedures provided on February 11, 
2020. 
 
You asked the Plan to pay for the dental surgery procedures (41820, 41899). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says primary dental procedures are 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 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 pay for the dental 
surgery procedures provided on February 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says comfort care does not meet the SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of the fall with a resulting 
pelvic fracture, the enrollee remained medically stable. The enrollee did not require any skilled nursing or 
rehab services on a daily basis at an inpatient level of care.  He was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care due to the injury sustained from the fall. The enrollee did not have any parental medication, 
complex wound care or nutrition given via a feeding tube.  She was medically stable without any acute 
exacerbations of chronic medical problems.  Her physical function was at or near her baseline and she could 
have received further services at a lower level of care. Admission to a SNF for inpatient skilled care was not 
medically necessary for continued comfort 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22869.) 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869). You say that you need this procedure for pain relief. The Plan denied your request. The Plan 
says the available medical evidence is conflicting to show if the procedure is safe and helpful. 
 
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 Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the device is 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of 
Interlaminar/Interspinous Process Stabilization/Distraction Device (22869.)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical X-ray 
(D0220), a periodontal maintenance procedure (D4910), and a dental extraction (D7210) performed on August 
11 to August 18, 2020. 
 
You asked the Plan to pay for a limited oral evaluation, a periapical X-ray, a periodontal maintenance 
procedure, and a dental extraction. You say that these services should be covered per the Plan website. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 pay for a limited 
oral evaluation (D0140), a periapical X-ray (D0220), a periodontal maintenance procedure (D4910), and a 
dental extraction (D7210) performed on August 11 to August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not covered under the current Medicare Category B 
Investigational Device Exemption Requirements. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. In this circumstance 
therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one 
randomized prospective trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results.   
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. The device should still be considered 
experimental or investigational. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMS system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services rendered on September 7, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until November 3, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the physician services rendered on September 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down positioning chairs provided from May 20, 
2020, and June 10, 2020. 
 
You asked the Plan to pay for the provided item. You say that you needed the chairs after your eye surgery. 
The Plan denied your request. The Plan says the device was recommended as a precaution to prevent 
complications following surgery. 
 
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 pay for the face-down positioning chairs provided from May 20, 2020, 
and June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified preventive procedure, by report (D1999) 
provided September 3, 2020. 
 
You asked the Plan to pay for the dental service. You say that you really need this taken care of. You have 
medical bills and cannot pay. The Plan denied your request. The Plan says this service is not covered under the 
plan benefits. 
 
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 pay for 
unspecified preventive procedure, by report (D1999) provided September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dynasplint (E1810) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the knee is functional. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested E1810 Dynasplint is not medically necessary for the enrollee's condition. The 
documentation indicates that the enrollee has not been using the Dynasplint, because he continues to feel it has 
not been beneficial. The enrollee feels his range of motion of the right knee plateaued a few months ago, and 
feels it is unchanged from his last PT visit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dynasplint (E1810) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950) provided on May 19, 2020. 
 
You asked the Plan to pay for core build up. You say that the service 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 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. Specifically, the service is not listed in the Plan?s benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pay for core build up 
(D2950) provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance 
(E0673) provided on September 24, 2020. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat PAD is not eligible for 
reimbursement. A PCD coded as E0675 is used only for peripheral artery disease. Other PCD codes are not 
used for this condition. PCD related accessories are eligible for reimbursement only when the appropriate, 
related base PCD meets coverage criteria for that type of PCD. The file shows CPT code E0675 was billed 
along with E0673. As E0675 is not eligible for payment, E0673 is also not payable in this case. Therefore, we 
decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673) 
provided on September 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you called for a van 
which for some reason was only available Monday - Friday. You don't feel because this happened on a Sunday 
that you should be burdened with the $225 fee. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these 
services. 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 ambulance services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for plastic surgery services (CPT 13101 and CPT 13132) provided to the 
enrollee on August 25, 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 that CPT 13101 and 13132 have an MUE value of 1, and the provider billed 2 units.  
 
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 
the denied codes is: 
 
CPT 13101: 
 
Repair, complex, trunk; 2.6cm to 7.5cm 
 
CPT 13132: 
 
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, 2.6cm to 7.5cm 
 
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 pay for the services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the enrollee 
underwent the excision of three malignant lesions on three anatomic areas. These were billed with three 
separate excision codes. The created defects were repaired with intermediate/complex closures. The codes for 
these repairs lump together two of the three anatomic areas. As such, only two closure codes were submitted, 
representing the total sutured lengths in the two anatomic areas. This is supported by the documentation and 
should be paid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
plastic surgery services (CPT 13101 and CPT 13132) provided to the enrollee on August 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5512, A5500). 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that the items are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 diabetic shoes and inserts. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal evidence of diabetes or a detailed neuromuscular 
or musculoskeletal examination of the feet indicating evidence of a need for these shoes and inserts for your 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diabetic shoes and inserts have not been met. Therefore, we decided that the 
Plan does not have to pre-approve diabetic shoes and inserts (A5512, A5500).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 x-ray services provided, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) for tooth #22. 
 
You asked the Plan to pre-approve a prefabricated post and core (D2954) for tooth #22. 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 a 
prefabricated post and core (D2954) for tooth #22.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa. 
 
You asked the Plan to pre-approve Pradaxa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Pradaxa.  
 
Benefits for Pradaxa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a capsulotomy (26525) performed June 8, 2020. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the services billed. 
 
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 26525 is Capsulectomy or capsulotomy; interphalangeal 
joint, each joint. 
 
We find that CPT code 26525 is not supported in the medical record. Specifically, insufficient clinical 
documentation was provided to verify the service at issue was performed. Based on this information, we 
decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for a capsulotomy (26525) performed June 8, 2020.