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

 
We decided that the Plan does not have to pre-approve impression and custom preparation; oral surgical splint 
(21085). 
 
You asked the Plan to pre-approve the oral surgical splint. You say that you have a lot of jaw pain. You say 
that your provider informed you that if you do not get the splint, your jaw might close shut. You also say that 
you have been trying to get this done for over a year. The Plan denied your request. The Plan says the claim 
denied correctly. 
 
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. Additionally, the oral splint you are asking the Plan to pre-approve 
involves the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pre-approve impression and custom preparation; oral surgical splint (21085).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 8, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion and lumbar laminectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not have a recent imaging study within the past six months that shows nerve root 
compression or spinal instability. Surgery is not needed 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion and lumbar laminectomy for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says skilled medical care is not needed at this time. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that there are 
no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services 
on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery with fluoroscopic guidance for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this was medically necessary. The Plan denied 
your request. The Plan says the records do not show rapidly progressive or very severe symptoms of 
neurogenic claudication. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of recent physical therapy for back pain. More conservative measures are 
needed. There are no severe neurologic deficits documented. The surgery is not needed 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery with fluoroscopic guidance for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that the enrollee has 
hypoglycemia unawareness and a significant change with regimen that requires more frequent monitoring. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic 
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. 
 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 therapeutic continuous glucose monitor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this procedure is 
medically necessary The Plan denied your request. The Plan says the requested procedure is investigational and 
non-covered. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is only limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective or safe treatment for the noted pathology. More research is 
needed to show safety and efficacy. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 17, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on March 17, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 
11, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 code 93042 billed for date of service December 11, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet cabinet (E0694). 
 
You asked the Plan to pre-approve an ultraviolet cabinet. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested item have not 
been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that an ultraviolet cabinet is covered for 
selected patients with generalized intractable psoriasis.  
 
In this case, the medical record does not support that the enrollee has generalized intractable psoriasis. Based 
on this information, we decided that Medicare rules for coverage of an ultraviolet cabinet have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an ultraviolet cabinet (E0694).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator (L8679, 64555). 
 
You asked the Plan to pre-approve the nerve stimulator. You say that the stimulator placement is medically 
necessary. The Plan denied your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that any ear or auricular electrical devices (e.g., 
DYANSYS) are non-covered by Medicare as electrical acupuncture. 
 
We looked at the file and Medicare rules. The type of stimulator being placed is considered electrical 
acupuncture and is non-covered under Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the nerve stimulator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a nerve stimulator (L8679, 64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1832) for the left knee, provided on April 
11, 2022. 
 
You asked the Plan to pay for a knee orthosis. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
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 for the supplies provided in this case. 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 a knee orthosis (L1832) for the left knee, provided on April 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluations (D0140) provided on April 19, 2022, 
and May 24, 2022. 
 
You asked the Plan to pay for evaluations. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a limited oral evaluation (D0140) is not covered under the 
supplemental 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 limited 
oral evaluations (D0140) provided on April 19, 2022, and May 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the debridement of nails provided on February 11, 2022. 
 
You asked the Plan to pay for the debridement of nails. You say that your services were provided at the 
enrollee's residence and the facility has proper authorization. The Plan denied your request. The Plan says that 
the rendering provider is an OON provider and there was no approved authorization. Also, the services 
rendered were not urgent or emergent. 
 
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. The claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. Therefore, we decided 
that the Plan has to pay for the debridement of nails provided on February 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on February 24, 2022, by an 
OON provider. 
 
You asked the Plan to pay for radiology services. You say that the claim should be paid at the Medicare 
allowable rate. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for radiology services provided on February 24, 2022, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on February 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for x-ray provided on February 23, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual 
policy or by Medicare. 
 
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 for you 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 (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on February 
9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility (SNF) services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on 
February 9, 2022, by an out-of-network (OON) provider.