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

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that your fingers are callused from being pricked so many 
times. The Plan denied your request. The Plan says the medical criteria for a CGM 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 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
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 June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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 
periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and 
extraction, erupted tooth or exposed root (elevation and/or forceps removal (D7140) provided on October 31, 
2022. 
 
You asked the Plan to pay for the dental services. You say that there was a long wait to see an in-network 
provider, and you could not wait that long. You say the billed services should be covered by your insurance. 
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. These services are not a covered benefit under any 
circumstance. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first 
radiographic image (D0220) and extraction, erupted tooth or exposed root (elevation and/or forceps removal 
(D7140) provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on October 06, 2022. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration. 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 wound care provided on 
October 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9610), IV sedation  first 
15 minutes (D9239), IV sedation  each subsequent 15-minute increments, (D9243) alveoloplasty without 
extractions, four or more teeth per quadrant (D7320) and removal of impacted tooth (D7240). 
 
You asked the Plan to pre-approve dental services. You say that you need this dental work done in preparation 
of getting dentures. The Plan denied your request. The Plan says these services are not covered under your 
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. D9610, D9239, D9243, D7320 
and D7240 are not covered under the Plans dental benefits. 
 
  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 
therapeutic parenteral drug (D9610), IV sedation  first 15 minutes (D9239), IV sedation  each subsequent 15-
minute increments, (D9243) alveoloplasty without extractions, four or more teeth per quadrant (D7320) and 
removal of impacted tooth (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) Teeth #3, 
14, and surgical access to an implant body (D6011) Teeth #3, 14. 
 
You asked the Plan to pre-approve the dental services. You say that your dental work is nearing completion and 
you do not wish to change the medical plans. 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. This benefit includes the 
requested surgical placement of implant body (D6010) and surgical access to an implant body (D6011) but is 
limited up to  two implants covered per year, or up to four implants covered for edentulous patients. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You have 
pre-authorization from January 26, 2023, to April 26, 2023, for D6010, Teeth #8 and 9, and D6011, Teeth #8 
and 9. Therefore, your benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve surgical placement of implant body (D6010) Teeth #3 and 14, and surgical access to an implant body 
(D6011) Teeth #3 and 14.
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 (D0210), a cleaning (D1110), and a resin-based composite (D2391) for tooth #5 provided 
by an out-of-network provider on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you were covered by the 
provider, and you do not understand why the services are being denied. 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 (D0210), a cleaning 
(D1110), and a resin-based composite (D2391) for tooth #5 provided by an out-of-network provider on October 
5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard. 
 
You asked the Plan to pre-approve the dental services. You say that you need the occlusal guard, so you do not 
break anymore teeth due to grinding. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental 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 an 
occlusal guard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
  We looked at the file and Medicare rules. Specifically, we have confirmed that you do not meet the intensive 
care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 days, or 3 or 
more emergency room visits in the last 60 days. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Therefore, we decided that the Plan does not have to pre-
approve the SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on November 27, 2022. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that there is a valid POD that was 
received. The Plan denied your request. The Plan says the date of service does not match the date of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, specifically the date of delivery was November 21, 2022, 
which does not match the dates of the invoice or the date or service. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the supply allowance for a continuous glucose monitor (CGM) provided on November 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5257 x 2) and the 
hearing aid/assistive listening device (V5267) purchased from the out-of-network (OON) provider on  
August 25, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items were purchased from 
an out-of-network provider, without prior authorization. 
 
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 issue reimbursement from out-of-network providers only in cases involving 
emergencies, out of area urgent care, and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to issue reimbursement for these items.  Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5257 x 2) and 
the hearing aid/assistive listening device (V5267) purchased from the out-of-network (OON) provider on 
August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional months rental for a Group 2 power 
wheelchair (K0822). 
 
You asked the Plan to pre-approve the power wheelchair rental. You say that you disagree with the denial for 
additional power wheelchair rental. The Plan denied your request. The Plan says that the 13-month rental 
period has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that DME has a 13-month rental period.  
 
We looked at the file and Medicare rules. The record shows the enrollee received the power wheelchair in 
December 2021. The 13-month rental period has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve eight additional months rental for a Group 2 power wheelchair (K0822).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth number 3. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial and no 
procedure has been done. 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 authorization number 
202212225714326, when the Plan approved a crown for tooth number 2. Therefore, we decided that the Plan 
does not have to pre-approve a crown for tooth number 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 26, 
2022. 
 
You asked the Plan to pay for the dental service. You say that there was nothing determined during the office 
visit, and you should not be charged for it. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the limited oral evaluation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on October 26, 2022.  
 Your complaint about the procedure not rendering results is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided on 
December 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had a damaged crown that was covered so 
you would not think this is the same service. 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 the date of service of July 20, 2019. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0210) 
provided on December 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
March 16, 2022. 
 
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 the records do not support the services billed. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 not supported by the medical records. Our reviewer found that the provided records do not 
document a comprehensive history. A comprehensive history requires 4+ elements in the history of present 
illness, 10+ organ systems in the review of systems and 3 elements for past/family/social history. The provided 
record does not meet this standard for a comprehensive history. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (AFO) provided on October 13, 2022. 
 You asked the Plan to pay for the AFO. You say that the proper documentation was sent. The Plan denied your 
request. The Plan says the referring physician documentation does not mention the braces. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The documentation provided did not demonstrate that the 
provider who signed the prescription for the AFO was treating the enrollee. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an ankle foot orthosis (AFO) provided on October 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. 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. 
 
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-3. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
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-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
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 the CGM helps monitor your 
sugar level. The Plan denied your request. The Plan says requested CGM is not considered medically 
necessary, and the enrollee did not meet the Medicare criteria for a CGM. 
 
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. 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. The documentation also 
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 Freestyle Libre 3 CGM 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).