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

 
We decided that the Plan does not have to pre-approve Dexcom therapeutic CGM reader and sensors (CPT 
code(s): K0553, K0554). 
 
You asked the Plan to pre-approve the CGM. You say that your blood sugar is always fluctuating, and you rely 
on someone to check your sugar levels. You state the supplies that are given are not easy to use, especially 
when no one is around to assist. You state it would be much easier with the monitor. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 shows you do not take multiple insulin injections 
per day, you are not on an insulin pump and there are no notes that state you cannot take insulin. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Dexcom therapeutic CGM reader and sensors (CPT code(s): 
K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network coverage for a transesophageal 
echocardiogram (CPT code 93312) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that you have been seeing this provider for nineteen 
(19) years and you trust this doctor. The Plan denied your request. The Plan says if you choose to use an out-of-
network provider, your share of costs for your covered services may be higher. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
As a Plan member, you can receive care from either a network provider or an out-of-network provider. If you 
choose to use an out-of-network provider, your share of costs for your covered services may be higher. In 
addition, if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the 
full cost of the services you receive. As the requested provider and facility are out-of-network providers, in-
network coverage is denied. Therefore, we decided that the Plan does not have to pre-approve in-network 
coverage for a transesophageal echocardiogram (CPT code 93312) to be provided by an out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard wheelchair (CPT code K0001). 
 
You asked the Plan to pre-approve the standard wheelchair. You say that the enrollee has been trying to get the 
wheelchair approved since May 4, 2022. The Plan denied your request. The Plan says medical records were not 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the standard wheelchair 
have been met. Medical records were not provided to verify if the enrollee meets the Medicare criteria. 
Therefore, we decided that the Plan does not have to pre-approve the standard wheelchair (CPT code K0001).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electrical stimulation therapy and ultrasound therapy 
provided on April 22, 2022, by a chiropractor. 
 
You asked the Plan to pre-approve the electrical stimulation therapy and ultrasound therapy. You say that you 
would like these services covered as they provided relief of your pain. The Plan denied your request. The Plan 
says services other than the manual manipulation of the spine to correct subluxation are not covered. 
 
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 pre-approve the electrical stimulation therapy and ultrasound therapy provided on 
April 22, 2022, by a chiropractor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS system. 
 
You asked the Plan to pre-approve the CardioMEMS system. The Plan denied your request. The Plan says this 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is a lack 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 enrollees 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 the CardioMEMS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reduction of osseous tuberosity (D7485). 
 
You asked the Plan to pre-approve these services. You say that there is a fragment of bone left in your jaw after 
another tooth was extracted. The Plan denied your request. The Plan says that the service or item in question is 
not covered under your 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 pre-approve 
reduction of osseous tuberosity (D7485).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (11444, 11406, 11404, 11402) provided on 
August 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services are included in the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery  
 
We looked at the file and Medicare rules. Payment for the services (11444, 11406, 11404, 11402) provided on 
August 17, 2021, is included in the global surgical payment for the procedure (15788) provided on July 27, 
2021. This procedure has a 90-day global period. 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 the 
services (11444, 11406, 11404, 11402) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown. 
 
You asked the Plan to pre-approve the crown. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not a covered benefit under the plan. The Plan states the maximum dental 
plan coverage for this year has been reached based on paid claims for the same tooth. 
 
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. This service requested for 
crown replacement cannot be approved. Restorative services are not a covered benefit under this dental plan. 
Therefore, we decided that the Plan does not have to pre-approve the crown.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography (95886), nerve conduction studies 
(95908), neuromuscular junction testing (95937) and EEG (95955) billed on January 6, 2022. 
 
You asked the Plan to pay for the needle electromyography (95886), nerve conduction studies (95908), 
neuromuscular junction testing (95937) and EEG (95955). The Plan denied your request. The Plan says 
procedure codes 95886, 95908, 95937, and 95955 are not supported by the medical records submitted. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records to 
support the denial. The Plan has not forwarded any clinical information and we are unable to determine if the 
Plan was justified in denying the billed services. It is the burden of the Health Plan to substantiate their denial 
with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for the needle electromyography (95886), nerve conduction studies (95908), neuromuscular 
junction testing (95937) and EEG (95955) billed on January 6, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) panel testing (87799, 
87798, 87482 and 87150) provided on April 7, 2022. 
 
You asked the Plan to pay for urine PCR testing. You say that his testing provides expedited results which 
means that the enrollee may be treated before the condition worsens. The Plan denied your request. The Plan 
says the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. PCR testing is considered unproven and therefore is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. PCR testing is considered unproven and not medically necessary. The review has 
determined that a urinary PCR panel is not medically necessary or reasonable in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) panel testing (87799, 87798, 87482 and 87150) 
provided on April 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on January 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (CPT code D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you suffer from periodontal disease and 
this procedure is necessary for you to clean the remaining debris for a successful deep cleaning. The Plan 
denied your request. The Plan says the service is not a covered benefit under 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. The services are not listed in 
your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan 
does not have to pre-approve gingival irrigation - per quadrant (CPT code D4921).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for home health services provided from 
April 26, 2021, to July 19, 2021. 
 
You asked the Plan to reimburse you for home health services. You say that you proceeded with private pay as 
you under the pretext that it was not a covered service. The Plan denied your request. The Plan says except for 
emergency care, we cannot pay a provider who is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that this provider does not participate in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for home health services provided 
from April 26, 2021, to July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and 
complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says you exhausted your benefit frequency limit. 
 
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 July 2, 2021. Therefore, we decided that the Plan 
does not have to pre-approve complete denture - maxillary (CPT code D5110) and complete denture - 
mandibular (D5120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled therapy, skilled nursing, and social 
work visits. 
 
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. The rules say that an enrollee must be homebound for home health care 
services to be 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 home health skilled therapy, skilled 
nursing, and social work visits.. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found there is no evidence in the submitted records that the enrollee has a considerable and taxing 
effort to leave home. The pressure ulcer noted on June 27, 2022 is stage I and not an indication for skilled 
nursing. Given that the enrollee is not homebound, the home health services are not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled therapy, skilled nursing, and social work visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the requested IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty (25447) and tendon transfer or transplant 
(26480) provided on February 25, 2022. 
 
You asked the Plan to pay for the arthroplasty (25447) and tendon transfer or transplant (26480). The Plan 
denied your request. The Plan says non-physician practitioners are not recognized as Medicare providers and 
are not able to bill separately for services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty (25447) and tendon 
transfer or transplant (26480) provided on February 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn (J7324). 
 
You asked the Plan to pre-approve Gelsyn. You say that the requested drug is medically necessary for the 
enrollee's treatement. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Monovisc, Orthovisc, or Synvisc. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed one of the plan's preferred step one alternatives. The record does not indicate that 
the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Gelsyn (J7324).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #30 and 31 (D7210), bone replacement 
grafts on tooth #30 and 31 (D7953), and biological materials on tooth #30 and 31 (D4265). 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says extractions (D7210), bone replacement grafts (D7953), and biological 
materials (D4265) 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 pay for 
extractions of tooth #30 and 31 (D7210), bone replacement grafts on tooth #30 and 31 (D7953), and biological 
materials on tooth #30 and 31 (D4265).