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

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction; non-surgical access 
(D3331) provided January 5, 2022. 
 
You asked the Plan to pay for the treatment of root canal obstruction. You say that you pay extra for dental 
coverage and feel this should be covered. The Plan denied your request. The Plan says this service is not 
covered under your 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 the 
treatment of root canal obstruction; non-surgical access (D3331) provided January 5, 2022.  
 Your complaint about the quality of you dental coverage 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter, a continuous glucose monitor 
(CGM) (K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the enrollee is testing her blood 
glucose once daily and injecting insulin once a week. The enrollee is having pain in her fingers and getting 
overwhelmed, causing her to panic. The Plan denied your request. The Plan says the enrollee does not meet 
prior authorization criteria. 
 
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 or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Dexcom G6 transmitter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 transmitter, a continuous glucose monitor 
(CGM) (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230), or pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis provided on December 16, 2021 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the intraoral periapical x-rays and to pay more for the periodic oral evaluation, 
bitewing x-rays, and prophylaxis. You say that the dental policy handbook shows that routine dental cleaning 
x-rays are included at 50% for OON visits, which is what you had. The Plan denied your request. The Plan says 
intraoral periapical x-rays are not a covered expense under your dental plan. The Plan also says that these 
services were performed by a non-participating provider, and you are responsible for any difference between 
the Maximum Allowable Fee and the amount the provider bills you for the service. 
 
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, first intraoral periapical x-ray (D0220) 
and additional intraoral periapical x-ray (D0230) are not among those covered under this benefit. The contract 
also says that you are responsible for a 50% coinsurance for the periodic oral evaluation (D0120) and bitewing 
x-rays (D0274), plus the difference between the billed amount and allowed amount because these services were 
received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray 
(D0220) and additional intraoral periapical x-ray (D0230), or pay more for the periodic oral evaluation 
(D0120), bitewing x-rays (D0274), and prophylaxis provided on December 16, 2021 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral at the in-network benefit 
level. 
 
You asked the Plan to pre-approve an out-of-network referral at the in-network benefit level. You say that the 
service should be covered. The Plan denied your request. The Plan says you are receiving this care out-of-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these out-of-network services at the in-network benefit level.  Therefore, we decided 
that the Plan does not have to pre-approve an out-of-network referral at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve the office visit. You say that you are appealing the denial for an office visit. 
The Plan denied your request. The Plan says this provider does not accept Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit to be 
provided by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 27, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was age-related 
osteoporosis without osteoporotic fracture and gastroesphageal reflux. She has not tried and failed the Plan's 
required drugs, an oral bisphosphonate and zoledronic acid. The records do not show that the required drugs 
would be contraindicated or less effective; therefore, the Prolia is 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 Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet light cabinet (E0694). 
 
You asked the Plan to pre-approve the ultraviolet light cabinet. You say that the light cabinet is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that  an ultraviolet light cabinet is only covered for a 
diagnosis of Psoriasis. 
 
We looked at the file and Medicare rules. The record does not show the enrollee has a diagnosis of Psoriasis. 
Based on this information, we decided that Medicare rules for coverage of the ultraviolet light cabinet have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light cabinet 
(E0694).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable sensors for continuous blood glucose 
monitor (K0553). 
 
You asked the Plan to pre-approve the disposable sensors. You say that you feel that this is medically 
necessary. You do not want to wait until you are insulin dependent. You were in better compliance with 
wearing the device and do not want to have to stick yourself all those times a day. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria as the records show that your diabetes is managed 
with oral medications only. 
 
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 the disposable sensors have not been met. 
Therefore, we decided that the Plan does not have to pre-approve disposable sensors for continuous blood 
glucose monitor (K0553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an 
inpatient basis, at a SNF level of care as of May 6, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization because the IRF care is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have pain persisting after a motor 
vehicle accident in October of 2021. You have no completed any physical therapy for this. You have not tried 
other recent conservative treatments for the back pain, such as non-steroidal anti-inflammatory drugs 
(NSAIDs), which is the standard of care. There is no recent examination documenting a red flag diagnosis to 
justify bypassing conservative treatments. The MRI is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for 
the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that these are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that your doctor ordered the stockings. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from November 11, 2021, to November 18, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs you received are not self-
administered drugs as you cannot go into a drug store and purchase them over the counter. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs 
you received are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from November 11, 2021, to November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee alignable system. 
 
You asked the Plan to pre-approve the requested services. You say that code L5910 will be used to make the 
required alignment changed to improve gait. The Plan denied your request. The Plan says the alignable system 
cannot be used with the approved preparatory prosthesis. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 Medicare does not pay for any items or services that are not reasonable and necessary for 
the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. In 
this case, the requested items exceed the enrollees medical need as his current approved preparatory prosthesis 
is non-alignable. At this time, the alignable system is not appropriate for the enrollees functional level. 
 
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 a below knee alignable system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair for the enrollee. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that this is not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 8, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 an epidural injection provided on 
November 8, 2021 have been met. The Health Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on November 8, 2021.