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

 
We decided that the Plan does not have to pay for the surgical boot/shoe (L3260) provided on September 6, 
2022. 
 
You asked the Plan to pay for the surgical boot/shoe. You say that you would like the plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the surgical boot/shoe (code L3260) is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that surgical shoes/boots are noncovered for all 
indications, regardless of the reason. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical boot/shoe have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgical boot/shoe (L3260) provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7311) and intra-socket biological 
dressings (D7922). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary, 
and you need them done at the same time as the extractions. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because alveoloplasty and intra-socket biological dressings 
are not covered by the Plan. 
 
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 
alveoloplasty (D7311) and intra-socket biological dressings (D7922).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the Freestyle Libre 3 CGM. You say that it is medically necessary for you to 
get this CGM and it should be covered. The Plan denied your request. The Plan says the requested CGM is not 
considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Freestyle Libre 3 is not specified as a product 
that may be billed using code E2103.  
 
  We looked at the file and Medicare rules. The records show that you are requesting coverage of a non-
adjunctive CGM. As of January 1, 2023, the appropriate coding for a non-adjunctive CGM is E2103. The 
Freestyle Libre 3 is not specified as a product that may be billed using code E2103. Therefore, the Freestyle 
Libre 3 is not eligible for reimbursement. 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 3 therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a resin-based composite (D2392) for tooth 
#2 provided on October 14, 2022. 
 
You asked the Plan to waive the coinsurance for the dental service. You say that you received a denial letter, 
and the dental service should be covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly, and the enrollee is responsible for the contracted fee. 
  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 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 class 2 basic services. White fillings on posterior teeth will be processed as a silver filling and 
the patient is responsible for up to the contracted fee. The total amount allowed for the resin-based composite 
(D2392) was $183 which was changed to the least costly resin-based composite (D2150) with a total allowed 
amount of $135. The difference between them for a contracted fee was $48 ($183 allowed amount - $135 
allowed amount). The coinsurance charged on the resin-based composite (D2150) was $27 ($135 allowed 
amount x 20% coinsurance). The total cost share for the resin based composite (D2150) was $75 ($48 
contracted fee + $27 coinsurance). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you have been asked to pay a $75 cost 
share for the dental service. This item/service falls within the Medicare preferred dental option 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 a resin-based composite (D2392) for tooth #2 
provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral 
radiographic images (D0220 and D0230), bitewings (D0274), and a cleaning (D1110) provided by an out-of-
network provider on September 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services would be covered and 
would like reimbursement for the paid services. 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), intraoral radiographic images (D0220 and D0230), 
bitewings (D0274), and a cleaning (D1110) provided by an out-of-network provider on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 9, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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 pay for the durable medical equipment provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that the sensors are medically 
necessary for the enrollee to control their diabetes. The Plan denied your request. The Plan says the Medicare 
criteria was 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft at time of implant placement tooth #29 
(D6104) provided on November 2, 2022. 
 
You asked the Plan to pay for the bone graft tooth #29 (D6104). You say that you are asking the Plan to cover 
the bone graft that you had to pay out-of-pocket. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 the bone 
graft at time of implant placement tooth #29 (D6104) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you will not pay because the dental office did a 
lousy job. 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on May 
26, 2020. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you received a 
collection notice for an unpaid balance, but this service should have been covered. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total amount you owe is $464.11 ($2,320.56 allowed amount x 20% = 
$464.11). Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab 
injection provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental case presentation (D9450) provided on October 4, 
2022. 
 
You asked the Plan to pay for a dental case presentation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
case presentation (D9450) provided on October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 02, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic testing provided 
on September 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
veterinary clinic called the ambulance so you feel you should not be responsible for the bill. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
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 August 2, 2022. 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 ambulance response and treatment with no 
transport provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device. 
 
You asked the Plan to pre-approve CGM device. You say that a CGM device is medically necessary. The Plan 
denied your request. The Plan says a CGM device is not medically necessary. 
 
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 CGM device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
October 07, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copaymet. The Plan denied your request. The Plan says this cost sharing was charged 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 $350 
copayment for outpatient hospital services/outpatient hospital surgery. 
 
You have been asked to pay a $350 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/outpatient hospital surgery 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 copayment for outpatient hospital services provided on October 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has not started therapy yet. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee 
can safely receive the care they need in another setting. 
 
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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia services during an epidural steroid injection 
(ESI). You asked the Plan to pre-approve the requested services. You say that you are terrified of needles. The Plan 
denied your request. The Plan says you do not meet the requirements for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that anesthesia or sedation during pain management 
services are only covered under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you have a history of cervical radiculopathy and right shoulder pain. An initial cervical 
transforaminal epidural steroid injection (TFESI) with sedation was requested. In this case, there is no specific 
clinical rationale for the use of sedation for the requested cervical epidural steroid injection. Per the coverage 
criteria, even in those with a needle phobia and anxiety, typically, oral anxiolytics suffice. In exceptional and 
unique cases, documentation must clearly establish the need for such sedation. The records do not show that 
anesthesia services are medically reasonable or necessary for the procedure. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve anesthesia services during an epidural steroid injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can get the services they need in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The enrollee has improved medically and can receive a lower 
level of care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.