Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1852). 
 
You asked the Plan to pre-approve a knee brace. You say that this brace is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested knee brace is subject to the criteria 
listed in the Medicare rules section. 
 
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 knee brace. Our reviewer says that the 
requested knee brace is not medically reasonable and necessary. Our physician reviewer found there is no 
evidence of a detailed properly performed neuromuscular examination or gait evaluation. There is no evidence 
of true instability on a physical exam. The "objective" does not indicate pathological laxity with objective 
measurements of any laxity of the knee. There is no evidence of a recent surgery or injury to the knee. There was no recent evidence of a gait evaluation or reference to ambulation. The September 9, 2020, document does 
note you performs water aerobics but there is no evidence in the documentation that indicate that you require 
the requested knee brace. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee brace (L1852).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and two resin-
based composites (D2391 x2) provided on January 21, 2022, and January 25, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and resin-based composites. You say that 
when you enrolled in this Plan in December of 2021, the agent confirmed that the treating provider was in-
network. You also say that you were never informed that the treating provider was no longer an in-network 
provider. The Plan denied your request. The Plan says services performed by an OON provider are not covered 
because your healthcare plan does not have OON benefits. The Plan also says that the provider has been OON 
since August 18, 2021 and you had not called to verify benefits since November 2, 2020. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and two resin-based composites (D2391 x2) provided on 
January 21, 2022, and January 25, 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 cleaning (D1110), periodic oral exam (D0120) and 
dental x-rays (D0220, D0230, D0274) provided on July 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your coverage did not 
include dental benefits. The Plan denied your request. The Plan says your plan did not have dental benefits at 
the time of services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve 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 pay for the dental cleaning (D1110), 
periodic oral exam (D0120) and dental x-rays (D0220, D0230, D0274) provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), implant 
removal (D6100), and bone replacement graft (D7953) provided on December 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 the 
surgical placement of implant body (D6010), implant removal (D6100), and bone replacement graft (D7953) 
provided on December 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total shoulder arthroplasty and injection and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total shoulder arthroplasty and injection. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam image capture (D0364) provided on January 
14, 2022. 
 
You asked the Plan to pay for the cone beam image capture. You say that this service was necessary as the 
issue wasn't accurately picked up by other methods. The Plan denied your request. The Plan says this service is 
not covered by your dental 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 the cone 
beam image capture (D0364) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crowns (D2751) for teeth #8 and 
#9. 
 
You asked the Plan to pre-approve crowns. You say that these teeth have a lot of wear and require crowns. The 
Plan denied your request. The Plan says crowns are not necessary to fix these teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns when 
the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for crown restorations (D2751) for teeth #8 and 
#9. Our physician reviewer found the documentation shows incisal wear on these teeth; however, there does 
not appear to be significant coronal breakdown to warrant crown restorations rather than other restorative 
procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns have not been met. Therefore, we decided that the Plan does not have to 
pre-approve white glass with metal crowns (D2751) for teeth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this request is not covered. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You are a medically complex patient with 
exertional dyspnea and hypoxemia. There is restrictive lung disease with elevation of the right hemidiaphragm, 
although fluoroscopy shows normal movement of both diaphragms. There may be an element of obstructive 
lung disease. There is hypertrophic cardiomyopathy, cardiac valvular disease, diastolic dysfunction, and 
pulmonary hypertension. On a single arterial blood gas while hospitalized, the PaCO2 was 44, which is near normal. There is severe obesity, with the possibility of mild obesity-hypoventilation syndrome, but obstructive 
sleep apnea has been excluded. You may benefit from BiPAP support during sleep, which can provide the 
average volume-assured pressure support mode. Medicare does not cover a home ventilator when used as 
BiPAP. Our physician reviewer found that your condition does not meet Medicare criteria for a portable 
ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (23430) provided on June 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 23430 
is a column II code to column I code 23472. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (23430) provided on June 4, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement services (36247, 
36245,36246 and 36140) provided on November 4, 2021. 
 
You asked the Plan to pay for the selective catheter placement services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an assistant at 
surgery may not be paid for these services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 36247, 36245,36246 and 36140. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an 
assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that 
Medicare coverage criteria for the selective catheter placement services have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement services (36247, 36245,36246 
and 36140) provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 21, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept device procedure (64628, 64629). 
 
You asked the Plan to pre-approve the intracept device procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 intracept device procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the service is experimental and more research is needed to show its 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 intracept device procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the intracept device procedure (64628, 64629).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have no other 
services in the area and your family is unable to help. The Plan denied your request. The Plan says this request 
exceeds your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
 We looked at your request, the records in the case file, and the rules. Additional trips cannot be approved 
because the benefit plan does not cover more than ten (10) one-way trips per plan year. Your 2022 EOC states 
that enrollees must pay a $10 copayment for up to 10 one-way trips to plan-approved locations every year. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and the smart 
check device (K0108). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The items at issue in this appeal do not serve purposes that are primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and the smart check 
device (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implanted crown (D6065), and a prefabricated 
abutment (D6056) for teeth #7, #8, #9, and #10 to be provided by a participating provider. 
 
You asked the Plan to pre-approve an implanted crown (D6065), and a prefabricated abutment. You say that 
you cannot chew. You say that you would like the Plan to approve these services. The Plan denied your 
request. The Plan says the requested dental services are not covered 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 an 
implanted crown (D6065), and a prefabricated abutment (D6056) for teeth #7, #8, #9, and #10 to be provided 
by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion (E0190). 
 
You asked the Plan to pre-approve a positioning cushion. You say that this is medically necessary. The Plan 
denied your request. The Plan says this device is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a positioning cushion (E0190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computerized ophthalmic diagnostic imaging (92133) 
provided on September 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON diagnostic imaging. You say that you were not aware that you were not 
contracted with this Plan and required prior approval. The Plan denied your request. The Plan says out-of-
network services are covered only in certain limited circumstances. The service at issue was not urgent or 
emergent, nor was it pre-approved. 
 
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 computerized ophthalmic diagnostic imaging 
(92133) provided on September 8, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. While you may benefit from physical therapy, and occupational therapy, your rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 23 and 27, retainer 
crowns (D6740) for teeth # 23 and 27, and pontics (D6245) for teeth # 24, 25, and 26. 
 
You asked the Plan to pre-approve the dental services. You say that you need a bridge. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the fixed bridge is not medically necessary. Our physician reviewer found the provided documentation 
indicates that 3 lower anterior teeth will be replaced. Since there are more than the allowed number of missing 
teeth, the Plan would not provide coverage for a fixed bridge. Based on the provided documentation, the 
reviewer found that the requested bridge is not medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core build up (D2950) for teeth # 23 and 27, retainer crowns (D6740) for teeth # 23 
and 27, and pontics (D6245) for teeth # 24, 25, and 26.