Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on June 06, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Specialist office visits. 
 
You have been asked to pay a $30 copayment for specialist office visit. This item/service falls within the 
Specialist office visits benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. 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 waive the copayment for specialist 
office visit provided on June 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies (A4239). 
 
You asked the Plan to pre-approve CGM supplies. 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. 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose 
monitor (CGM) supplies (A4239).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve Opdivo and Yervoy. 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 may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo and Yervoy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the requested use of Opdivo and 
Yervoy is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Yervoy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implants. 
 
You asked the Plan to pay for dental implants. You say that you need these dental implants. The Plan denied 
your request. The Plan says the requested dental service is not a covered benefit. 
 
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 dental 
implants.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 92960. 
 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 93010 
is a column II code to column I code 92960. 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 93010 billed for date of service June 18, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT angiography as part of renal transplant workup 
 
You asked the Plan to pre-approve the CT scan. You say that the services should be covered as you disagree 
with the denial, and they are medically necessary. The Plan denied your request. The Plan says that the services 
denied correctly as they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the CT angiography in this case in not done 
due to a disorder, it is being done as a preoperative procedure. Kidney transplantation requires suitable arterial 
flow to supply the kidney.  Enrollees with kidney failure have high incidence of vascular disease.  It is often a 
challenge to find a suitable artery to use to supply the organ. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT angiography as part of renal transplant workup  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation- new or established patient 
(D0150) and comprehensive oral evaluation- new or established patient (D0210) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had these services previously; however, the 
provider never completed the work. You went to this provider to receive dental work and this claim should be 
paid. 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 comprehensive oral evaluation- new or established patient (D0150) and comprehensive oral 
evaluation- new or established patient (D0210) but each is limited to one procedure every three plan years. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation- new or established patient (D0150) and 
comprehensive oral evaluation- new or established patient (D0210) was exhausted on date of service May 30, 
2022. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation- new or 
established patient (D0150) and comprehensive oral evaluation- new or established patient (D0210) provided 
on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown (D2750) tooth 
# 12. 
 
You asked the Plan to pre-approve dental services. You say that the requested service is how the provider said 
they can fix the tooth. The Plan denied your request. The Plan says this service is 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. White glass with high gold 
content crown (D2750) is 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 
white glass with high gold content crown (D2750) tooth # 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534, 
A6540. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as you 
disagree with the denial and they are medically necessary. The Plan denied your request. The Plan says the 
services denied correctly as they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6534, 
A6540 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6534, A6540.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyrvaya. 
 
You asked the Plan to pre-approve Tyrvaya. You say that the medication is 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 Tyrvaya.  
 
Benefits for Tyrvaya 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 pay for physician services provided on August 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that it is not the doctor's responsibility to obtained 
prior authorization. The Plan denied your request. The Plan says services provided by an out-of-network 
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 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 physician services provided on August 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services provided on November 15, 2021. 
 
You asked the Plan to pay for the surgical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that non-contracted providers may not balance 
bill the member. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the surgical services by a contract provider. The file does not show that the Plan 
provided notice that the surgical services would not be covered. Under Medicare rules, this means the surgical 
services are considered approved by the Plan. The file does not show that the Plan has made any payments to 
the provider at issue. Therefore, we decided that the Plan has to pay for the surgical services provided on 
November 15, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6104) and a sinus augmentation 
(D7951). 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested dental services are not covered benefit. 
 
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 a 
bone graft (D6104) and a sinus augmentation (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4261) provided on August 16, 2022. 
 
You asked the Plan to pay for an osseous surgery. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 an 
osseous surgery (D4261) provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180). 
 
You asked the Plan to pre-approve a comprehensive periodontal evaluation. You say that you need these 
services. The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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 a 
comprehensive periodontal evaluation (D0180).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laminectomy for excision or evacuation of intraspinal lesion 
other than neoplasm coded 63267 provided on August 15, 2022. 
 
You asked the Plan to pay for laminectomy for excision or evacuation of intraspinal lesion other than 
neoplasm. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 63267 is not eligible for payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laminectomy for excision or evacuation of intraspinal lesion other than neoplasm have not been 
met. Therefore, we decided that the Plan does not have to pay for laminectomy for excision or evacuation of 
intraspinal lesion other than neoplasm coded 63267 provided on August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease with 
bronchiectasis. The record indicates that the enrollee was successfully treated with bilevel positive airway 
pressure (BiPAP). The provided primary source documentation does not contain sufficient detailed information 
in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), periapical first 
radiographic image (D0220), periapical each additional radiographic image (D0230), bitewings - four 
radiographic images (D0274), cone beam CT image capture with field of view of both jaws, with or without 
cranium (D0383), Prophylaxis (D1110), oral hygiene instructions (D1330), Surgical placement of Implant 
body; Endosteal Implant (x2) (D6010), second stage implant surgery (x2) (D6011), implant removal by report 
(x2) (D6100), bone graft at time of implant placement (D6104), remove interim implant component (D6198), 
Extraction erupted tooth or exposed root (D7140), Surgical removal of erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (x7) (D7210), and bone 
replacement graft for ridge preservation (x2) (D7953) provided on June 17, 2021, to May 23, 2022. 
 
You asked the Plan to pay for dental services. You say that you did not know the provider was not submitting 
your claims. 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. The rules say that claims for 
services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of 
service. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services represented by codes 
D1330, D6011, D6100, D7140, D7210, and D7953 are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for codes D1330, D6011, D6100, D7140, D7210, and D7953 
provided on August 23, 2021, to May 23, 2022. 
 
The record shows you received dental services represented by codes D0150, D0220, D0230, D0274, and 
D1110 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 codes D0150, D0220, D0230, 
D0274, and D1110 provided on August 10 and September 9, 2021. 
 
The record shows that a claim for codes D0383, D6010, D6104, D6198, and D7210 provided on June 17 and 
July 22, 2021, was not filed until August 19, 2022. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
codes D0383, D6010, D6104, D6198, and D7210 provided on June 17 and July 22, 2021.