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

 
We decided that the Plan has to pay for a crown - porcelain/ceramic (D2740) provided on September 29, 2022. 
 
You asked the Plan to pay for the crown - porcelain/ceramic. You say that you feel this should be covered 
because you thought crowns were covered for abrasion or attrition. You also say that you are covered for 
crowns. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
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 Plan covers a crown - 
porcelain/ceramic when the services are medically necessary and reasonable. 
 
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  a crown - porcelain/ceramic. Our 
reviewer says that the crown - porcelain/ceramic is medically necessary. Our physician reviewer found the 
documentation indicates that teeth #'s 30 and 31 exhibit severe coronal breakdown. Although the criteria states 
that breakdown due to attrition and/or erosion are not covered, crown restorations for these teeth are medically 
reasonable and necessary. There is no other treatment that would restore these teeth to good masticatory 
function and also prevent fracture of the remaining natural tooth structure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown - porcelain/ceramic have been met. Therefore, we decided that the Plan 
has to pay for a crown - porcelain/ceramic (D2740) provided on September 29, 2022.  
 
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 a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you have been a diabetic for 20 years 
and the pain of pricking your finger is unbearable at age 75. You also say that you are presently on 12 
medications and are attempting to simplify your lifestyle and feel that the GM system will help with that. The 
Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 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 use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
2 continuous glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is not approved for use in a stand-alone procedure as requested by the pain 
practitioner provider. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not 
intended for stand-alone use. The provided documentation does not corroborate this will not be a stand-alone 
procedure. In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Minuteman procedure, in this case, is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) provided on August 
23, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) 
provided on August 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve a quantitative calcium scoring. You say that you need to have this procedure 
because your doctor was concerned that you had a major blockage in your arteries. The Plan denied your 
request. The Plan says Medicare does not cover the requested study for screening purposes. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The records show that the test at issue in this appeal, a quantitative calcium scoring, is being requested by your 
provider solely for screening purposes. Specifically, this test was requested for a screening for heart disease. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve a quantitative calcium scoring (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership services (S9970) 
provided from October 17, 2021, through December 31, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not payable as the claim was submitted untimely. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 The Plans rules for coverage of gym benefits have not been met because the claim was submitted untimely for 
reimbursement. The Plan contract states that reimbursement requests for a prior year for the Wellness Benefit 
allowance must be received no later than March 31
st
 of the following year. The claim for the year 2021 was 
submitted untimely on December 8, 2022. Therefore, we decided that the Plan does not have to issue 
reimbursement for the gym membership services (S9970) provided from October 17, 2021, through  
December 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis with fluoroscopic guidance (procedure 
codes 20610 and 77002) rendered from April 18, 2022. 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is deemed to be experimental and investigational. 
 
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 that there is no documentation of a previous knee steroid injection for degenerative joint disease (DJD). 
There are no x-rays in the records showing severe tricompartmental knee DJD as read by a radiologist. 
 
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 arthrocentesis with fluoroscopic guidance (procedure codes 20610 and 77002) rendered 
from April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous microwave ablation of hepatic dome lesion 
rendered on September 20, 2022. 
 
You asked the Plan to pay for the services. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says the clinical value and effectiveness of percutaneous microwave 
ablation of hepatic dome lesion in the setting of metastatic cervical cancer have not been demonstrated in the 
peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this therapy is considered experimental and investigational at this time. Comparison with other ablative techniques would be useful. 
 
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 pay for percutaneous microwave ablation of hepatic dome lesion rendered on September 20, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the head. 
 
You asked the Plan to pre-approve the MRA. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service would report the same findings as in the already approved 
70553. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRA. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that the enrollee has 
had the worst headache of their life and has a history of epilepsy and deep vein thrombosis. With this history, 
the magnetic resonance imaging (MRI) of the brain (70553) is appropriate. However, the MRA of the brain - 
70544 for evaluation of vascular channels in the brain is also appropriate. This information could not only be 
gleaned from the MRI of the brain that was already approved. The requested examination would screen for 
cerebral aneurysm as well as venous thrombosis and should also be approved. 
 
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 MRA have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance angiography (MRA) of the head.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for tenolysis, flexor tendon; palm OR finger, each tendon rendered on June 
22, 2021. 
 
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 procedure code 26440-F2 x2 is not supported by the medical records submitted. 
 
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 26440 is "Tenolysis, flexor tendon; palm OR finger, each tendon." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite 
tenosynovitis present and digital stiffness despite the release of the A1 pulley in the middle and index finger. 
Therefore, a tenolysis of the flexor digitorum superficialis tendon was performed on the index finger and the 
middle finger. There was further middle finger flexor digitorum profundus tenolysis performed. Therefore, the 
records do support the use of CPT 26440. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
tenolysis, flexor tendon; palm OR finger, each tendon rendered on June 22, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Novolog. 
 
You asked the Plan to pre-approve these services. You say that you cannot afford the medication. The Plan 
denied your request. The Plan says the Part B drug is not eligible for a Part D tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for Part D tier 
exceptions. 
 
We looked at the file and Medicare rules. The requested drug, Novolog, is covered under Part B Medicare and 
is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a 
tier exception for Novolog.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 February 11, 2022. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and 
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures including routine post-delivery care 
(D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 December 23, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete dentures including routine post-
delivery care (D5110).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the abdomen rendered 
on November 20, 2022. 
 
You asked the Plan to pre-approve the MRA. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the diagnosis codes are not appropriate for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRA. Our reviewer says that the 
requested MRA is medically reasonable and necessary. Our physician reviewer found that the enrollee has 
renal failure and developed acute chest and abdominal pain. On 11/20/22, in the emergency department setting, 
the diagnosis to exclude was aortic dissection particularly in a patient with a recent left heart catheterization. 
Ordinarily, a computed tomography angiography (CTA) would have been done, but due to the renal failure, 
iodinated contrast could not be used. Therefore, the best available technique to evaluate the thoracic and 
abdominal aorta was MRA.  The exam had been recommended by a staff radiologist and documented in the 
records. 
 
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 MRA have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance angiography (MRA) of the abdomen rendered on November 20, 2022.  
 
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 an outdoor electric wheelchair. 
 
You asked the Plan to pre-approve an outdoor electric wheelchair. You say that an outdoor electric wheelchair 
is medically necessary. The Plan denied your request. The Plan says that the requested outdoor electric 
wheelchair is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an outdoor electric wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a radiologic examination, abdomen; 1 view rendered on August 3, 
2022. 
 
You asked the Plan to pay for the exam. You say that this should be paid for. The Plan denied your request. 
The Plan says that the service was not authorized. 
 
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 pay for the exam. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the indication for the one view abdomen film of 8/3/22 was constipation. This is a valid symptom 
for a one view abdominal film for the amount of colonic dilation and retained fecal material. This exam should 
be reimbursed. 
 
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 exam have been met. Therefore, we decided that the Plan has to pay for a 
radiologic examination, abdomen; 1 view rendered on August 3, 2022.  
 
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 a 4-wheel mobility scooter. 
 
You asked the Plan to pre-approve a mobility scooter. You say that your current scooter is not suitable for 
outside use. The Plan denied your request. The Plan says that requested scooter is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a 4-wheel mobility scooter.