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

 
We decided that the Plan does not have to pay for laboratory services provided on April 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the service was medically necessary. 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 laboratory services 
provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns, pontic, retainer crowns. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 authorization number A0230123120821. 
Therefore, we decided that the Plan does not have to pre-approve interim crowns, pontic, retainer crowns.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose system (CGM) receiver. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from a CGM. You also 
say that at this time the enrollee does not use insulin. The Plan denied your request. The Plan says the enrollee 
does 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 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 system (CGM) receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99401 provided on October 13, 2022. 
 
You asked the Plan to pay for procedure code 99401. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 code 99401 is not supported in the medical record. Specifically, procedure code 99401 has a 
status code of N under the Physician Fee Schedule and is a non-covered service per Medicare guidelines. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99401 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99401 provided on October 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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 benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting 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 an office visit provided 
on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBC benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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 benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve SSBCI benefits
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic (D6242 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because you 
cannot eat properly. 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 authorization number A0230118000310. 
Therefore, we decided that the Plan does not have to pre-approve pontic (D6242 x 5).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mesalamine. 
 
You asked the Plan to pre-approve Mesalamine. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Mesalamine is not covered under the enrollee's Medicare 
Part B benefit. 
 
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 Mesalamine.  
 
Benefits for Mesalamine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3425) and a bone graft (D3428) for tooth 
#14 provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the oral surgery was medically necessary and is 
a Medicare benefit. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the apicoectomy and bone graft 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 pay for an 
apicoectomy (D3425) and a bone graft (D3428) for tooth #14 provided on October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy and spine fusion (63047, 63048, 
22612, 22614, 22843). 
 
You asked the Plan to pre-approve lumbar laminectomy and spine fusion. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet medical 
requirements for coverage. 
 
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 lumbar laminectomy and spine fusion. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the imaging studies do not correlate with exam. The imaging studies do 
not show severe stenosis. The criteria for surgery not met. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar laminectomy and spine fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar laminectomy and spine fusion (63047, 63048, 22612, 22614, 
22843).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a therapeutic continuous 
glucose monitor (CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you previously got the 
CGM, and it is medically necessary to continue to use it. 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 supply 
allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the supply allowance for a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214), and endosteal implants 
(D6010). 
 
You asked the Plan to pre-approve endosteal implants. You say that you would like the Plan to approve and 
pay for these services. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 
partial lower denture (D5214), and endosteal implants (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for procedure code J2001. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code J2001 is bundled into 
payment for code 20611. 
 
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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service September 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve 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 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 therapeutic 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the deep sedation (D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that the requested service is medically 
necessary because of the dental work that needs to be done. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the deep sedation is 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 the 
deep sedation (D9222 and D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the panoramic film (D0330) and surgical extraction 
(D7210) for tooth #2 provided by an out-of-network provider on November 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should have paid more of the 
claim. The Plan denied your request. The Plan says the proper cost share was applied, and you are responsible 
for any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
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. 
 
  You have been asked to pay the cost sharing amount and the difference between the out-of-network providers 
charges and the Plans payment. The total amount billed for the panoramic film was $140 and the total allowed 
amount was $79.10 leaving a difference of $60.90 ($140 billed - $79.10 allowed). The total enrollee liability 
for the panoramic film was $70.90 ($60.90 difference + $10 copayment). The total allowed amount for the 
extraction was 535 and the total allowed amount was $203.47 leaving a difference of $331.53 ($535 billed - 
$203.47 allowed). The coinsurance amount for the extractions was $111.91 ($203.47 allowed x 55% 
coinsurance). The total enrollee liability for the extraction was $443.44 ($331.53 difference + $111.91 
coinsurance). 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 pay more for the panoramic film (D0330) and surgical 
extraction (D7210) for tooth #2 provided by an out-of-network provider on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary visit provided on August 26, 2022. 
 
You asked the Plan to pay for a domiciliary visit. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. 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 domiciliary visit 
provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 87798. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an IV infusion therapy provided on 
November 1, 2022. 
 
You asked the Plan to waive the coinsurance for an IV infusion. You say that you had to accommodate the 
hospital and had to appear three times. 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay $42.23 coinsurance for an IV infusion ($211.15 Allowed Amount x 20% 
coinsurance = $42.23 applied coinsurance). This item/service falls within the Medicare Part B drugs 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 coinsurance for an IV infusion therapy provided on November 
1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp vitality tests (D0460) and cone beam CT (D0364). 
 
You asked the Plan to pre-approve pulp vitality tests (D0460) and cone beam CT (D0364). You say that you 
need additional testing to determine what is happening with the nerve. The Plan denied your request. The Plan 
says these procedures are not covered. 
 
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 pulp 
vitality tests (D0460) and cone beam CT (D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified restorative procedure, by report tooth 
#10 (D2999), and unspecified periodontal procedure, by report (D4999). 
 
You asked the Plan to pre-approve codes D2999 and D4999. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 pre-approve an 
unspecified restorative procedure, by report tooth #10 (D2999), and unspecified periodontal procedure, by 
report (D4999).