Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluticasone/salmeterol. 
 
You asked the Plan to pre-approve Fluticasone/salmeterol. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Fluticasone/salmeterol.  
 
Benefits for Fluticasone/salmeterol may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CGM to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Trulicity.  
 
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. 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 follows Medicare rules. Medicare rules say that PTA is covered when specific criteria are met. 
 
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 revascularization services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not support the medical necessity of the procedures in question. The nature of the enrollees symptoms is 
not well documented. No ankle brachial indexes (ABIs) are provided. The computed tomography angiography 
(CTA) does not demonstrate significant iliac, femoral, or popliteal disease and the pulse examination is 
nonspecific. There is no evidence of limb threat documented. Tibial intervention in an enrollee without 
evidence of limb threat has a potential to do more harm than good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 30, 2022, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive periodontal evaluation (D0180) and 
prophylaxis (D1110) provided on July 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services should be covered. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay $80 for prophylaxis. You have also been asked to pay $197.60 for an evaluation. 
The record shows you received these services from an out-of-network provider and are being asked to pay the 
difference between the out-of-network providers charges and the Plans payment. 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 pay more for a comprehensive periodontal evaluation (D0180) and prophylaxis (D1110) 
provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), oral hygiene 
instructions (D1330), and cone beam computed tomography (CT) capture and interpretation with field of view 
of both jaws; with or without cranium (D0367) provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider should not have provided services 
not covered under your policy. The Plan denied your request. The Plan says your benefit for the additional 
intraoral x-rays has already been exhausted and the remaining services are 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, certain limitations apply. The record 
shows your benefit for the intraoral x-rays was exhausted on the same date of service July 18, 2022. The 2D 
oral/facial photographs, oral hygiene instructions and cone beam CT scan are not among your covered services. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), 
oral hygiene instructions (D1330), and cone beam computed tomography (CT) capture and interpretation with 
field of view of both jaws; with or without cranium (D0367) provided on July 18, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 81403 provided on June 14, 2022. We also decided the Plan does 
not have to pay for code G0452 provided on June 14, 2022. 
 
You asked the Plan to pay for the testing. You say that procedure-to-procedure modifier requirements were 
followed. The Plan denied your request. The Plan say code 81403 was not billed with the appropriate unique 
identifier. The Plan says code G0452 is not separately payable because the records do not support it was 
distinct from other services provided. 
 
We decided that the Plan has to pay for code 81403.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The record shows that the Plan has denied this service using rules that are only applicable to Molecular 
Diagnostics (MolDX) jurisdictions. These services were not provided in a jurisdiction in which MolDx rules 
apply. 
 
We decided that the Plan does not have to pay for code G0452.  
 
In this case, we have confirmed that code G0452 is a column II code to column I code 81403; however, G0452 
was billed with a modifier.  
 
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 testing. Our reviewer says that the medical records do not 
support the use of procedure code G0452 as separately distinct from the approved procedure code of 81403. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for code G0452 provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, pouch on armrest side (K0108). 
 
You asked the Plan to pre-approve the pouch. You say that this equipment is medically necessary for mobility 
for the enrollee. The Plan denied your request. The Plan says that pouches are not medically necessary and are 
a convenience item. 

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 
We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of the 
pouch have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair 
component or accessory, not otherwise specified, pouch on armrest side (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve an electrical connection, expandable controller and harness. 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 follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an electrical connection, expandable 
controller and harness. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the enrollee does not require the multiple power drives as she does not have the conditions that make the 
multiple tilt and recline power devices 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 an electrical connection, expandable controller and harness have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electrical connection between the 
wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 6, 2022.

You asked the Plan to pay for the dental services. You say that you received these services without being advised if they were authorized by the Plan. 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 Plan's 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 benefits for the requested services were exhausted on dates of service July 13, 2020, and November 11, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and crown (D2750) provided on 
July 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that it was necessary to have this dentist make your 
crowns. 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 the core buildup (D2950) and crown (D2750) provided on July 5, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure coded A4556 and A4630 billed for date of service 
April 27, 2022. 
 
You asked the Plan to pay for procedure code A4556 and A4630. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says payment for code A4556 and A4630 is bundled into payment for code 
E0730. 
 
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 A4556 
and A4630 is a column II code to column I code E0730. 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 procedure coded A4556 and A4630 billed for date 
of service April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture- maxillary (D5110) and complete 
denture-mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting to have your dental 
coverage to start over again so you can get new dentures. You say that the set you have were not made 
correctly. 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 Plan's coverage rules apply in this case. This benefit includes the 
requested complete denture- maxillary (D5110) and complete denture-mandibular (D5120) but is limited to 1 
upper complete and 1 lower complete denture every 5 years, including routine post-delivery care) or partial 
dentures (upper and lower) (1 upper and/or 1 lower partial denture every 5 years, including routine post-
delivery care) includes necessary extractions to fit dentures (unlimited). 

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested complete denture- maxillary (D5110) and complete denture-mandibular 
(D5120) was exhausted on date of service January 29, 2021. Therefore, we decided that the Plan does not have 
to pre-approve complete denture- maxillary (D5110) and complete denture-mandibular (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary and 
cannot be safely managed at a lower level of care. The Plan denied your request. The Plan says based on 
Medicare guidelines the long term acute care hospital services you are requesting do not meet the requirements 
for approval. 
 
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 the enrollee was admitted with sepsis in the setting of an infected wound and 
osteomyelitis. The record indicates that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH facility. 
 
 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental 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 Plan's 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 complete denture - maxillary (D5110), and mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lubiprostone. 
 
You asked the Plan to pre-approve Lubiprostone. You say that the enrollee has been dealing with this condition 
for years. You also say that the enrollee has tried and failed Linzess twice. The Plan denied your request. The 
Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan also says the requested drug is 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 pre-approve Lubiprostone.  
 Benefits for Lubiprostone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod insulin pump. 
 
You asked the Plan to pre-approve the requested services. You The Plan denied your request. The Plan says the 
service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that external infusion pumps are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. Disposable drug delivery systems are non-covered devices because 
they do not meet the Medicare definition of durable medical equipment. 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 an Omnipod insulin pump.  
 
Benefits for the requested services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.