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

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says you must receive covered services from contracted providers unless the 
service is for an emergency or when it is medically necessary for you to go out-of-network because a 
contracted provider is unable to provide you the same service. You do not meet either of these criteria, 
therefore, the request of receiving the services from this non-contracted provider is denied. 
 
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 
physician's services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nephrology consult to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a nephrology consult. You say that the requested provider is closer to your 
home. The Plan denied your request. The Plan says this is available 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 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 nephrology consult to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain fused to metal crown (noble metal) (D6061) Tooth #3, 4 and 5. 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested services 
approved. 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. Custom fabricated abutment  
includes placement (D6057) and abutment supported porcelain fused to metal crown (noble metal) (D6061) are 
not covered under the Plans dental benefits. 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6057 and D6061 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain fused to metal 
crown (noble metal) (D6061) Tooth #3, 4 and 5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transforaminal epidural injection provided on October 05, 
2022. 
 
You asked the Plan to pay for a transforaminal epidural injection. You say that this is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a transforaminal 
epidural injection provided on October 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 24, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 August 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve insertion of an ILR. 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 certain cardiac event monitors capture electrical 
activity with a single electrode attached to the skin. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an ILR in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were traveling and needed these services. 
The Plan denied your request. The Plan says these 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 laboratory services provided on September 19, 
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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not 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 request for authorization from the enrollees physician indicates 
that the enrollee does not 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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary to help control your sugar 
levels. The Plan denied your request. The Plan says the Medicare criteria was not 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on October 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim was not billed with the required MolDX Dex-Z code. 
 
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 Plan states that the claim was not billed with the required Dex-Z code per 
Local Coverage Determination (LCD) L36807; however, this LCD is not binding for Part B Medicare for the 
state of Colorado where the testing was performed. The Plan has not provided any documentation or binding 
Medicare rules to support that the claim is not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on October 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a POV provided on November 8, 2022. 
 
You asked the Plan to pay for the POV. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the supplier is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a POV provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventive medicine evaluation provided on December 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a preventive medicine evaluation. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was 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 a preventive medicine evaluation provided on 
December 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 March 9, 2022, June 14, 
2022, and September 27, 2022. Therefore, we decided that the Plan does not have to pay for the dental services 
on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutmentincludes placement (D6057) 
and the abutment supported porcelain fused to metal crown (high noble metal) (D6059) provided on January 9, 
2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are 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 items provided are not among those 
covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the custom fabricated abutmentincludes 
placement (D6057) and the abutment supported porcelain fused to metal crown (high noble metal) (D6059) 
provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) is an investigational question. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9126 billed for date of service June 1, 2022, 
to June 15, 2022. 
 
You asked the Plan to pay for procedure code S9126. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9126 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9126 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9126 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9126 billed for date of service June 1, 2022, to June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retrograde filling - per root (D3430) and apicoectomy - 
premolar (first root) (D3421) provided on October 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you pay for optional supplemental insurance, so 
you feel the services should be covered. 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. Retrograde filling - per root 
(D3430) and apicoectomy - premolar (first root) (D3421) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D3430 and D3421 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
retrograde filling - per root (D3430) and apicoectomy - premolar (first root) (D3421) provided on October 6, 
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 are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not 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 received from the enrollees physician indicates 
that the enrollee does not 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 fender lights (K0108) and screws (K0108). 
 
You asked the Plan to pre-approve fender lights and screws. The Plan denied your request. The Plan says that 
control lights are a convenience item and are not covered. The Plan also says that the power wheelchair is 
under warranty. 
 The Plan must follow Medicare rules. Medicare rules say that repairs for items under warranty are not covered. 
The rules also say that control lights are not covered due to not being primary medical in nature. 
 
We looked at the file and Medicare rules. The record shows you received the power wheelchair on June 28, 
2022. The Plan confirmed that you have a warranty for the power wheelchair. The requested fender lights are 
not covered since they do not serve a medical purpose. Therefore, we decided that the Plan does not have to 
pre-approve fender lights (K0108) and screws (K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive hearing test (92557) and the typanometry test 
(92567) provided on December 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for these services. 
 
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. Specifically, the Plans contract states that one routine hearing exam is covered 
per year. The Plan has stated that you have exhausted the allowable benefit as you previously received this 
service on June 21, 2022. However, there has been no evidence submitted by the Plan that demonstrates this 
service was previously exhausted. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pay for the comprehensive hearing test (92557) and the 
typanometry test (92567) provided on December 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 May 17, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on March 1, 2023.