Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection wheelchair seat cushion, adjustable, 
width less than 22 inches, any depth (E2622). 
 
You asked the Plan to pre-approve a skin protection wheelchair seat cushion. You say that the enrollee sits a lot 
in a recliner throughout the day and acquired this pressure ulcer. The Plan denied your request. The Plan says 
the requested cushions are not being used appropriately. The enrollee's therapist has noted that she will use this 
in her recliner. The cushions are only covered by Medicare if they are used in a wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a skin protection wheelchair seat cushion have not been met. Specifically, records show that you 
need the requested cushion for a recliner. Medicare rules say that the requested cushion is to be used with a 
wheelchair, not a recliner. Therefore, we decided that the Plan does not have to pre-approve a skin protection 
wheelchair seat cushion, adjustable, width less than 22 inches, any depth (E2622).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 14-day Sensor. You say that the enrollee has difficulty 
pricking their finger to check blood glucose due to their age. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria because the records do not show that the enrollee is using insulin three times 
or more each day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 14-day Sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on February 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient visit provided on February 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is experiencing pain. The 
Plan denied your request. The Plan says the services are not covered 
 
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 services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare 
coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve dental surgery services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive orthodontic treatment of the adult 
dentition (D8090) provided on December 15, 2020. 
 
You asked the Plan to pay more for the comprehensive orthodontic treatment. You say that you believe this 
amount is owed to you. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your supplemental preventive and comprehensive dental allowance was exhausted on date of service 
December 15, 2020. Therefore, we decided that the Plan does not have to pay more for the comprehensive 
orthodontic treatment of the adult dentition (D8090) provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an intraoral 
radiographic image (D0210), an upper partial denture (D5211), and a lower partial denture (D5212) provided 
from October 4, 2021, through December 6, 2021. 
 
You asked the Plan to pay more for the dental services. You say that the services were necessary and 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 a comprehensive oral evaluation (D0150), an 
intraoral radiographic image (D0210), an upper partial denture (D5211), and a lower partial denture (D5212) 
provided from October 4, 2021, through December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2021, billed with 
codes 81206, 81235 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported as billed. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 29, 2021, billed with codes 81206, 81235 and 81321.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic heart failure. 
The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014. The clinical 
study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device. 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 enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure System.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) and chiropractic manipulative 
treatment to regions other than spine (98943) provided from April 11, 2022, to April 26, 2022. 
 
You asked the Plan to pay for the office visit and chiropractic manipulative treatment to regions other than 
spine. You say that the plan has paid previous chiropractic services. The Plan denied your request. The Plan 
says these services are not covered by the plan when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) and chiropractic manipulative treatment to regions 
other than spine (98943) provided from April 11, 2022, to April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item was exhausted on date of service October 12, 2020. Specifically, the 
Plan contract states that one complete upper denture is covered every five years. You previously received this 
item on October 12, 2020, which was paid for by the Plan. Therefore, the allowable benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) on December 16, 2021. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation 
(D4346). You say that you would like to request reconsideration for payment. The Plan denied your request. 
The Plan says the service is not covered under the member's contract under any normal circumstances. 
 
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 scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation-problem focused 
(D0140), intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic 
image (D0230), and the panoramic radiographic image (D0330) provided on November 3, 2021. 
 
You asked the Plan to issue reimbursement for these dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation, intraoral-
periapical first radiographic image, and the intraoral-periapical additional radiographic image are not covered 
under this benefit. Additionally, services are not covered when received from an out-of-network provider. The 
services in this case were rendered by an out-of-network provider. Therefore, we decided that the Plan does not 
have to issue reimbursement for the limited oral evaluation-problem focused (D0140), intraoral-periapical first 
radiographic image (D0220), intraoral-periapical additional radiographic image (D0230), and the panoramic 
radiographic image (D0330) provided on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Coflex device (22867). 
 
You asked the Plan to pre-approve the insertion of a Coflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 a Coflex device. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device 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 a Coflex device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the insertion of a Coflex device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953) and the surgical removal of an implant (D6100). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft for ridge preservation-per site (D7953) and the surgical removal of an implant (D6100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement 
(D6057 x 2) and abutment supported porcelain/ceramic crowns (D6058 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the benefit for the requested items 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 enrollees benefit for the requested items was exhausted on date of service March 23, 2022. 
Specifically, the Plan provides coverage of two custom fabricated abutments and two abutment supported 
porcelain/ceramic crowns per calendar year. The enrollee previously received these items on March 23, 2022, 
which were paid for by the Plan. Therefore, the enrollee has exhausted the allowable benefit. Therefore, we 
decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement  
(D6057 x 2) and abutment supported porcelain/ceramic crowns (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an implant body: endosteal 
implants (D6010 x 3), prefabricated abutmentsincludes modification and placement (D6056 x 3), abutment 
supported retainers for porcelain/ceramic fixed partial dentures (D6068 x 3), and a porcelain/ceramic pontic 
(D6245). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit.  
 Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an implant body: 
endosteal implants (D6010 x 3), prefabricated abutmentsincludes modification and placement (D6056 x 3), 
abutment supported retainers for porcelain/ceramic fixed partial dentures (D6068 x 3), and a porcelain/ceramic 
pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments on tooth #29 and 30 (D6056). 
 
You asked the Plan to pre-approve abutments. You say that you would like these services to be covered. The 
Plan denied your request. The Plan says prefabricated abutments (D6056) are not covered by 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 pre-approve 
prefabricated abutments on tooth #29 and 30 (D6056).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional non-emergency transportation one-way 
trips. 
 
You asked the Plan to pre-approve 6 additional non-emergency transportation one-way trips. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says you have exhausted your 
transportation benefits. 
 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 60 one-way trips every calendar year to plan-approved locations for non-
emergency transportation 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 6 additional non-emergency transportation one-way trips.