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

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve a maxillary and mandibular partial dentures. You say that the service is 
medically necessary. The Plan denied your request. The Plan says you have exceeded the allowed benefit 
frequency. 
 
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, records indicate you received a partial denture in 
November 2016. This means you are not eligible for another partial denture until November 2021 and the 
service is not covered. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial 
denture (D5213) and mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle libre device (CPT Code K0554) and (K0553). 
 
You asked the Plan to pre-approve the device. You say that if you had a FreeStyle libre device you would be 
alerted quicker if you had a drastic change in blood sugar. The Plan denied your request. The Plan says you 
have not required frequent insulin adjustment based on blood glucose monitor testing. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. There is no indication that you require insulin shots at least three 
times a day or you use a continuous subcutaneous insulin infusion pump. Based on this information, we 
decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve FreeStyle libre device (CPT Code K0554) and (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested supplies are available to you from a 
preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred durable 
medical equipment and supplies providers. The rules say that a Medicare Health Plan must disclose to its 
members the benefits offered under the plan including applicable conditions and limitations. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-
preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the 
use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide 
documentation from your treating physician that the requested non-preferred brand, Freestyle Lite test strips are 
medically necessary. Diabetic testing strips are available from ACCU-CHEK and Trividia under your Plan 
benefit. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you require a power operated 
vehicle. The Plan denied your request. The Plan says that you can walk safely inside the home without any 
assistive devices. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power wheelchair repairs.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve tenodesis of long tendon of biceps identified with code 23430 and 
arthroplasty services identified with code 23472. 
 
You asked the Plan to pre-approve tenodesis of long tendon of biceps and arthroplasty services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the 
requested services are not medically necessary. 
 
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 tenodesis of long tendon of biceps and 
arthroplasty services. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee's condition is consistent with severe pain 
along with weakness in the shoulder, with limited range of motion. In this case, there was documented 
radiographic evaluation that revealed severe shoulder osteoarthritis. Range of motion was severely impacted, in 
addition to the persistent pain. The enrollee has ?gone through physical therapy, has taken nonsteroidal anti-
inflammatory drugs, icing, has had steroid injections, she has avascular necrosis?. The enrollee has evidence of 
severe arthritis (with symptoms of at least 6-12 months) that are not sufficiently managed with nonoperative 
measures. Therefore, these findings are sufficient to support the requested right shoulder total arthroplasty with 
biceps tenodesis as being 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 tenodesis of long tendon of biceps and arthroplasty services have been met. 
Therefore, we decided that the Plan has to pre-approve tenodesis of long tendon of biceps identified with code 
23430 and arthroplasty services identified with code 23472.  
 
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 waive the deductible for the office visit you had on August 20, 2020. 
 
You asked the Plan to waive the services. The Plan denied your request. The Plan says you are responsible for 
the cost share. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $900 deductible you must pay out-of-pocket before the Plan will pay 
its share for covered medical services.  
 
The service you asked the Plan to waive falls within the out-of-network physician services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $900 deductible you 
must pay out-of-pocket before the Plan will pay its share for covered medical services. This cost sharing is a 
contractual obligation that had not been met at the time the services was received on August 20, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit you had on 
August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 18. 
 
You asked the Plan to pre-approve the dental service. You say that core build up is necessary. The Plan denied 
your request. The Plan says core build up is not listed as a covered service. The Plan also says if a dental item 
or service is not listed or is listed with NC, then it is not covered. 
 
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 core 
build up (D2950) for tooth # 18.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require this 
transportation. The Plan denied your request. The Plan says that each one-way trip must not exceed 50 miles. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the intraosseous 
basivertebral nerve. 
 
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this 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 the RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that RFA of the intraossesous basivertebral nerve is considered an experimental/investigational 
procedure. Therefore, the request is deemed not medically reasonable or 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) of the intraosseous basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental filling provided on August 12, 2020. 
 
You asked the Plan to pay for the fillings. You say that you were not told about a limit on fillings. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
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.  
 
We looked at the file, and Medicare rules. The records show that you last received 2 fillings on February 3, 
2020. Your plan only covers two fillings per calendar year. Based on this information, we decided that the 
Plan's rules for coverage of the fillings have not been met. Therefore, we decided that the Plan does not have to 
pay for the dental filling provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of the length of time of compression stockings therapy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not meet coverage criteria and does not support the medical necessity 
of the treatment in question. It is not documented if the enrollee is experiencing lifestyle or mobility limiting 
pain attributable to the varicose veins. The enrollee was given an alternative compression device that should be 
easier to use, but there has not been documentation that the enrollee has failed this conservative effort. A strict 
application of coverage criteria is reasonable in this setting, as the enrollee has a history of diabetes, arthritis, 
hypertension, elevated lipids, and former smoking - so is at elevated risk for arterial insufficiency and other 
non-vascular etiologies for leg/ankle pain. The vascular provider has not documented satisfactory arterial 
perfusion in the medical records provided. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pacemaker replacement surgery 
provided on December 20, 2019. 
 
You asked the Plan to waive the coinsurance for the surgery. You say that you cannot afford this cost share. 
The Plan denied your request. The Plan says that the claim processed 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 20% 
coinsurance for surgery performed at an Outpatient Facility.  
 
You have been asked to pay a 20% coinsurance for the surgery. The surgery falls within the surgery performed 
at an Outpatient Facility 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 coinsurance for the 
pacemaker replacement surgery provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process 
stabilization/distraction device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction 
device. You say that this would benefit the enrollee. The Plan denied your request. The Plan says there is no 
indication that spinal surgery is not contraindicated. 
 
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 insertion of an 
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is 
experimental. More research is needed to show it is safe and effective. 
 
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 insertion of an interlaminar/interspinous process stabilization/distraction 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an 
interlaminar/interspinous process stabilization/distraction device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up (D2950). 
 
You asked the Plan to pre-approve the core build-up. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this 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 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 core 
build-up (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services provided to the enrollee on August 
25, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the medical records show the enrollee was billed for a screening mammography, code 
77067-26, for date of service August 25, 2020. The submitted documentation supports 1 (one) unit of 77067-
26, which was previously approved and paid.  There is no additional documentation supporting an additional 
study which was billed and remains denied. The reports submitted are duplicates of each other. Medicare billed 
criteria are not met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed as 
these services were previously billed and paid for the same enrollee and the same date of services. The records 
show no separate and distinct service which would allow payment of this claim. Medicare rules for coverage of 
this service have not been met. Therefore, we decided that the Plan does not have to pay for mammography 
services provided to the enrollee on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided to the enrollee on July 21, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider in question is out of 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 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 practitioner services provided 
to the enrollee on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the out of network cost share for the periodic oral 
evaluation (D0120), the periapical x-ray (D0220), the bitewing x-rays (D0274), and the prophylaxis (D1110) 
provided on September 29, 2020. 
 
You asked the Plan to reimburse the out of network cost share for the dental service. You say that there is a $0 
copayment for exams, cleanings, x-rays, and fluoride. You say that this same description is listed for both in 
network and out of network providers for a total maximum of $1000 for total dental claims for the calendar 
year. You say that there is no mention of a coverage cap, even though your dentist is out of network. You also 
say that the $135 should be covered. The Plan denied your request. The Plan says the provider in this case is 
out of network. The Plan also says that you may be billed by the out of network provider for any amount 
greater than the MAC payment made by the Plan to the provider. 
 
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 and the services you received are listed 
as covered, you may be billed more by an out of network provider if the charge is greater than the MAC 
payment made by the plan to the provider. Cost sharing is a contractual obligation under the plan and cannot be 
waived. Therefore, we decided that the Plan does not have to reimburse the out of network cost share for the 
periodic oral evaluation (D0120), the periapical x-ray (D0220), the bitewing x-rays (D0274), and the 
prophylaxis (D1110) provided on September 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) services 
provided on September 28, 2020. 
 
You asked the Plan to waive the copay for the MRI. You say that the service was not complete due to 
claustrophobia. The Plan denied your request. The Plan says a service was rendered, and the copay is a 
contractual obligation. 
 
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 $175 
copay for diagnostic imaging.  
 
You have been asked to pay a $117.29 for the MRI. Because the amount is less than the $175 copay, you were 
charged the lesser amount. The MRI falls within the outpatient diagnostic tests benefit category. Although the 
complete MRI was not performed, medical services were still rendered. 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 copay for the magnetic resonance imaging (MRI) services provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #12. 
 
You asked the Plan to pre-approve core buildup (D2950). You say that tooth #12 appears to have a lingual 
fracture. You say that core buildup and a crown are recommended to restore the tooth. 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 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 core 
buildup (D2950) for tooth #12.