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

 
We decided that the Plan does not have to pay for the Global Reach Cancer Genetic Panel provided on March 
1, 2021. 
 
You asked the Plan to pay for the Global Reach Cancer Genetic Panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The Global Reach Cancer Genetic Panel at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Global Reach Cancer Genetic Panel provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 Sensor. The Plan denied your request. The Plan says you do  
not require insulin three or more times daily. 
 
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 the Dexcom 
G6 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the special supplemental benefit for the 
chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says the provided documentation does not support that you meet the criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not need intensive care 
management. Therefore, we decided that the Plan does not have to pre-approve enrollment in the special 
supplemental benefit for the chronically ill (SSBCI).
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 a home ventilator is not medically 
necessary. If this enrollee has chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Decom G6 transmitter. 
 
You asked the Plan to pre-approve a Decom G6 transmitter. You say that a Decom G6 transmitter is medically 
necessary. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Decom G6 transmitter. Therefore, we decided that the Plan does not have to pre-approve a Decom G6 
transmitter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940, 98941) to 
be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic manipulative treatments (98940, 98941) to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia first 15 minutes 
(D9222) and deep sedation/general anesthesia each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve the dental services. You say that this is an emergency, and these services are 
medically necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's 
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 pre-approve deep 
sedation/general anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each subsequent 15-
minute increment (D9223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87503, 87632, and 87634 provided on July 14, 2022. 
 
You asked the Plan to pay for codes 87503, 87632, and 87634. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87503 and 87632 are not supported in the medical record. Specifically, respiratory 
panels with more than five respiratory pathogens performed in the Part B outpatient setting are considered not 
medically reasonable and necessary. In addition, a respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. 
 
In this case, we have confirmed that code 87632 is a column II code to column I code 78632. This claim has 
not been billed with an appropriate modifier to bypass the edit. 
 
Based on this information, we decided that Medicare rules for coverage of codes 87503, 87632, and 87634 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 87503, 87632, and 
87634 provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you have been using the device for about one year. 
You also say that it has helped you to not have to go on insulin and help keep your sugar down. The Plan 
denied your request. The Plan says you do  not require insulin three or more times daily. 
 
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 use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. The Plan denied your request. The 
Plan says that the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
records do not document that you have a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee or have significant edema of the lower extremities that requires an 
elevating leg rest. The provided records do not support that you are at high risk for skin breakdown (he is 
reported to walk short distances), has a history of pressure ulcer(s) or has had skin flap surgery. The records 
also do not document that you perform bladder self-catheterization or that you have increased muscle tone or 
spasticity to meet LCD criteria for the requested power option and the power tilt/recline. As the wheelchair 
base with multiple power option does not meet criteria for coverage, the requested wheelchair accessories are 
not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93308 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 93308. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93308 is bundled into payment for code 33016.  
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 93308 
is a column II code to column I code 33016. 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 93308 billed for date of service August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments (D6057) and abutment 
supported to crowns (D6059) for tooth #3 and #4 provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called prior to the date of service to verify 
that the dental procedures would be covered. The Plan denied your request. The Plan says the denial of 
payment for these services is correct because implants and all related services are not covered by the Plan. 
Also, it was verified the proper dental coverage was given to the enrollee. 
 
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 custom 
fabricated abutments (D6057) and abutment supported to crowns (D6059) for tooth #3 and #4 provided on 
December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral radiographic 
images (D0210), and resin-based composites (D2391, D2392, D2330 and D2393) for tooth #15, #19, #21, and 
#22 provided by an out-of-network provider on December 1, 2022, and December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network so 
the services should be covered. 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 limited oral evaluation (D0140), intraoral radiographic images (D0210), and resin-based 
composites (D2391, D2392, D2330 and D2393) for tooth #15, #19, #21, and #22 provided by an out-of-
network provider on December 1, 2022, and December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you would like help with any part of the 
utility benefits due to the increase prices of everything. The Plan denied your request. The Plan says there is no 
documentation that all the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the SSBCI benefits have been met. 
Specifically, medical records were requested but not received. Therefore, we decided that the Plan does not 
have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240 x3) 
and a retainer crown-porcelain fused to high noble metal (D6750 x2). 
 
You asked the Plan to pre-approve the dental services. You say that you feel cheated since you have a $5,000 
dental benefit. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 25, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal 
(D6240 x3) and a retainer crown-porcelain fused to high noble metal (D6750 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 anti-cancer 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Keytruda is not FDA-
approved for the enrollees diagnosis. The 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve phlebectomy (37765, 37766). 
 
You asked the Plan to pre-approve phlebectomy. 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 the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. 
 
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 phlebectomy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not meet 
coverage criteria. For tributary treatment such as stab phlebectomy to be considered medically necessary per 
coverage criteria, there needs to be persistent significant symptoms following successful treatment of truncal 
(saphenous) reflux with these symptoms existing more than 6 weeks after the reflux was treated and despite 
conservative efforts. Additionally, the veins to be treated need to be at least 4 mm in diameter. As you have not 
yet undergone saphenous vein reflux treatment, the above criteria have not been met. The health plan does not 
provide for simultaneous saphenous reflux treatment and tributary treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of phlebectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve phlebectomy (37765, 37766).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supporting a removable denture (D6110 and 
D6111). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental procedures are 
medically necessary to help the enrollee. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because implant and all related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supporting a removable denture (D6110 and D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing this denial. The Plan 
denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).