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

 
We decided that the Plan has to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are having trouble eating with having 
lost so many teeth. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a complete maxillary denture (D5110).  
 
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 endosteal implants on tooth #18 and 20 (D6010). 
 
You asked the Plan to pre-approve implants. You say that these services are medically necessary. The Plan 
denied your request. The Plan says endosteal implants (D6010) 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 
endosteal implants on tooth #18 and 20 (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve ultrasonic guidance for placement of radiation therapy fields. You say that 
the services meet Medicare guidelines for payment establishing IGSRT as a standard of care. The Plan denied 
your request. The Plan says there is no good evidence this is a prudent or medically effective maneuver. The 
request does not meet the Medicare or health plan coverage criteria. 
 
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 Ultrasonic guidance for placement of 
radiation therapy fields. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found certainly using ultrasound on a daily basis 
is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general- citations below) is not necessary. 
Billing for daily simulations or IGRT would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for placement of radiation therapy fields have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ultrasonic guidance for placement of 
radiation therapy fields (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller (E2313) 
and an expandable controller upgrade (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says although there are three approved 
power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control 
these power options through the joystick. 
 
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. There is no medical 
need to control these power options through the joystick. Therefore, we decided that the Plan does not have to 
pre-approve a harness for upgrade to expandable controller (E2313) and an expandable controller upgrade 
(E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that a new partial denture is medically 
necessary. 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 benefit for the requested item or service was exhausted on date of service September 21, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x 4), provisional crowns (D2799 x 11), 
core build up (D2950 x 11), pontics (D6240 x 4), retainer crowns (D6750 x 5), and alveoloplasty (D7311 x 4). 
 
You asked the Plan to pre-approve crowns, core build up, pontics, and alveoloplasty. You say that you disagree 
with the denial of dental services. The Plan denied your request. The Plan says that provisional crowns 
(D2799), core build up (D2950), pontics (D6240), retainer crowns (D6750), and alveoloplasty (D7311) are not 
covered by your dental benefits. The Plan also says that your benefit for crowns (D2740) 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, provisional crowns, core build up, 
pontics, retainer crowns, and alveoloplasty are not among those covered under this benefit. The record shows 
your benefit for crowns (D2740) has been exhausted during this authorization request. Therefore, we decided 
that the Plan does not have to pre-approve crowns (D2740 x 4), provisional crowns (D2799 x 11), core build up 
(D2950 x 11), pontics (D6240 x 4), retainer crowns (D6750 x 5), and alveoloplasty (D7311 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation to your 
dialysis appointments three times per week. The Plan denied your request. The Plan says this request exceeds 
your benefit limit. 
 
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 up to 48 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K1-67 Bio Marking testing. 
 
You asked the Plan to pre-approve K1-67 Bio Marking testing. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that the clinical care of patients with breast cancer 
depends upon the accurate diagnosis and the assessment of biomarkers. 
 
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 K1-67 Bio Marking testing. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has grade 2 triple negative breast cancer. Coverage for the requested test is 
excluded by the rule. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K1-67 Bio Marking testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve K1-67 Bio Marking testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the glasses provided on May 13, 2022. 
 
You asked the Plan to pay more for the glasses. You say that you were told most of the cost of the new lenses 
and frames would be covered. The Plan denied your request. The Plan says your allowance has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $100 every 24 months for eyewear. 
 
We looked at the file and the Plan's rules. The record shows that your eyewear allowance was exhausted on 
May 13, 2022. Based on this information, we decided that the Plan's rules for coverage of the glasses have not 
been met. Therefore, we decided that the Plan does not have to pay more for the glasses provided on May 13, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight massage therapy visits. 
 
You asked the Plan to pre-approve the massage therapy visits. You say that your primary care physician has 
recommended deep massage therapy. The Plan denied your request. The Plan says massage therapy is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve eight massage therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on December 21, 2020. 
 
You asked the Plan to pay for the observation care discharge day management. You say that this claim was 
submitted within the allowed timeframe. The Plan denied your request. The Plan says this claim was received 
on April 7, 2022, which is past the allowed 12-month timeframe. 
 
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 the observation care discharge day management was not filed until April 7, 
2022. 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 observation care discharge day 
management (99217) provided on December 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have utilized your benefit of 10 one-way trips for this plan year. The Plan also says that extra one-way trips 
cannot be approved. 
 
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 up to 10 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyewear provided on May 24, 2022. 
 
You asked the Plan to pay an additional amount for eyewear. The Plan denied your request. The Plan says the 
Plan paid the maximum allowable eyewear benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear benefit 
amount. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided 
on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit to transfer to the requested facility. The Plan denied your request. The Plan says this member does not 
meet the medical necessity guidelines for LTACH admission. 
 
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. Our 
physician reviewer found 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 Plan. Our physician reviewer also found that the Plan 
has approved ongoing care in the current acute care setting. 
 
   
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens 
(V2781), polycarbonate or equal lens (V2784), and vision item or service (V2799) provided on May 24, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lens, polycarbonate or equal lens, and 
vision item or service. You say that you needed new lenses and it had been over one year since your last exam. 
The Plan denied your request. The Plan says the Plan paid for eyeglasses provided to you on May 17, 2021. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two years. 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows you received glasses on May 17, 2021, which were 
covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the anti-
reflective coating, progressive lens, polycarbonate or equal lens, and vision item or service have not been met. 
Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive 
lens (V2781), polycarbonate or equal lens (V2784), and vision item or service (V2799) provided on May 24, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve these services. You say that you are not getting quality blood samples. The 
Plan denied your request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
continuous glucose monitor (CGM) supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH 
admission criteria and his current care warrants LTACH level of care. The Plan denied your request. The Plan 
says the criteria for LTACH coverage have not been met. 
 
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. Our 
physician reviewer found the enrollee requires additional acute care services, including weaning attempts, that 
can safely be administered at the current facility until more appropriate for transfer. The enrollee does not 
require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is 
not medically necessary, as it would not be clinically advantageous at this time. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary, and continued acute hospital stay was 
offered, until the enrollee could discharge to a lower level of care. 
 
 
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. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) provided 
on December 24, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation. You say that you were transported to 
the hospital by ambulance, and paid $75 for the ambulance copay. The Plan denied your request. The Plan says 
the fire department did not provide ambulance transportation services, but only first aid services. The Plan also 
says you were transported by a separate ambulance company who was reimbursed for the transfer. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) 
provided on December 24, 2021.