Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (S9122). 
 
You asked the Plan to pre-approve HHA services. You say that it is recommended that the enrollee's HHA 
services be reinstated. The Plan denied your request. The Plan says there is no documentation that the enrollee 
is receiving skilled nursing care on an intermittent basis, physical therapy, speech-language pathology, or has a 
continuing need for occupational therapy. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 
 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 HHA services. Our reviewer says that 
HHA services are not reasonable and necessary for the enrollee. Our physician reviewer found the clinical 
documentation does not show a care plan that would require 30 hours of home health aide services, thus the 
requested home health aide services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services (S9122).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a facet joint RFA. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet joint RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the most recent RFA 
in April 2021 provided only 10% relief of pain. The review has determined that the enrollee does not meet the 
coverage criteria detailed in the LCD. The review has determined that the requested procedure is not medically 
reasonable or necessary. 
 
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 facet joint RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet joint radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0210) and the comprehensive exam 
(D0150) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you would be charged 
by a new dentist and having new x-rays done. 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 services was exhausted on date of service June 11, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral x-rays (D0210) and the comprehensive exam 
(D0150) provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a single metal-ceramic crown (D6059) and a custom fabricated 
abutment (D6057) provided on June 24, 2022. 
 
You asked the Plan to pay for a single metal-ceramic crown (D6059) and a custom fabricated abutment 
(D6057). You say that you were told by the Plan that crowns were covered. The Plan denied your request. The 
Plan says that these particular services 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. The Plan covers one crown per 
tooth every 60 months (5 years). 
 
We looked at the file, Medicare rules and the Plan rules. The Plan contract says that one crown per tooth is 
covered every 5 years. The Plan contract does not say which specific codes or services are excluded from this 
benefit. Based on this information, we decided that the Plan's rules for coverage of a single metal-ceramic 
crown (D6059) and a custom fabricated abutment (D6057) have been met. Therefore, we decided that the Plan 
has to pay for a single metal-ceramic crown (D6059) and a custom fabricated abutment (D6057) provided on 
June 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Alginate Dressing Wound (CPT A6197) provided on  
January 27, 2022. 
 
You asked the Plan to pay for Alginate Dressing Wound. You say that Alginate Dressing Wound was 
medically necessary. The Plan denied your request. The Plan says Alginate Dressing Wound does not meet the 
Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 pay for Alginate Dressing Wound. Our reviewer 
says that Alginate Dressing Wound is not medically necessary. Our physician reviewer found that the enrollee 
is a 67-year-old female who has a sacral pressure ulcer, stage 3 and pressure ulcer of left buttock, unstageable. The progress notes from January 21, 2022 stated the enrollee had moderate serosanguineous drainage with mild 
odor without eschar or epithelialization of the sacral wound and no drainage, no odor, no eschar of the left 
buttock wound. Alginate Dressing Wound was provided on January 27, 2022, one for each of two wounds. 
However, the provided documentation does not clearly describe the left buttock wound as a moderately to 
highly exudative full thickness wound less than 16 square inches in size to meet the Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alginate Dressing Wound have not been met. Therefore, we decided that the 
Plan does not have to pay for Alginate Dressing Wound (CPT A6197) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet coverage criteria for approval of this item. 
 
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 the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease in the setting of lung cancer. The 
record indicates that the enrollee was successfully treated with BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability if needed. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 14, 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 June 14, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered because the only 
other time you were seen by the provider was for a cleaning. 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 limited oral evaluation - problem focused (D0140) was exhausted on date 
of service April 20, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - 
problem focused (D0140) provided on July 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the provided 
documentation does not show that the enrollee has tried one of the preferred drugs, or that the enrollee has 
medical reasons that prevent them from using one of the preferred drugs. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our reviewer says that the 
enrollee does not meet the coverage criteria for Hyalgan. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no indication that 
the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture  resin base (D5211) provided on 
June 20, 2022. 
 
You asked the Plan to pay for a maxillary partial denture  resin base (D5211). You say that you assumed this 
service was somewhat covered. The Plan denied your request. The Plan says this service is 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 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 a 
maxillary partial denture  resin base (D5211) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 2, 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 July 26, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the enrollee is pre-diabetic and not 
insulin dependent and therefore does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve supply allowance used with a therapeutic CGM device 
(K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing order for weekly drug testing services 
(G0480, 80307) through the end of the year. 
 
You asked the Plan to pre-approve drug testing services. You say that these services are necessary for ongoing 
monitoring of the enrollee's substance abuse. The Plan denied your request. The Plan says the documentation 
shows that the enrollee will be receiving broad-spectrum drug panels at every weekly appointment, which is 
explicitly not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that standing orders for drug testing are not 
reasonable and necessary.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing services have not been met. Specifically, the requested services are for a standing 
order for weekly drug testing of a specific enrollee, which is not covered. Therefore, we decided that the Plan 
does not have to pre-approve a standing order for weekly drug testing services (G0480, 80307) through the end 
of the year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction erupted tooth or exposed root (D7140) and 
surgical removal of residual tooth roots- cutting procedure (D7250) provided on May 16, 2022. 
 
You asked the Plan to pay for dental services. You say that your teeth were infected and had to be surgically 
removed, so the Plan should pay for at least part of the bill. The Plan denied your request. The Plan says this 
service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Extraction erupted tooth or 
exposed root and surgical removal of residual tooth roots- cutting procedure are not covered under the Plans 
dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested extraction erupted tooth 
or exposed root (D7140) and surgical removal of residual tooth roots- cutting procedure (D7250) are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extraction 
erupted tooth or exposed root (D7140) and surgical removal of residual tooth roots- cutting procedure (D7250) 
provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (92610) provided on February 6, 2020. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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 92610 is not supported in the medical record. Specifically, records show this service 
was performed in the home setting. There is a more appropriate code to describe the service when performed in 
the home setting (G0153). Based on this information, we decided that Medicare rules for coverage of the 
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (92610) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a limited oral evaluation (D0140), a 
panoramic x-ray (D0330), and a complete maxillary denture (D5110) provided on June 8, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you do not understand why 
these services were not covered. The Plan denied your request. The Plan says your dental allowance has been 
exhausted. 
 
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 have a $1,000 
dental allowance for supplemental preventive and comprehensive dental services. The contract also says that 
you are responsible for any amount above the allowance amount. 
 
The record shows your dental allowance was exhausted during the processing of this claim. You have been 
asked to pay a total of $1,317 for the dental services received on June 8, 2022. This item/service falls within the 
dental services 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 cost share for a limited oral evaluation 
(D0140), a panoramic x-ray (D0330), and a complete maxillary denture (D5110) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), a comprehensive 
oral evaluation (D0150), anterior resin-based composites (D2332, D2335), and posterior resin-based 
composites (D2392, D2393) provided from June 11, 2021, to December 21, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you are on a fixed income and cannot 
afford the bill. The Plan denied your request. The Plan says 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 difference between the out-of-network providers charges and the Plans 
payment. 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 a limited oral evaluation (D0140), a 
comprehensive oral evaluation (D0150), anterior resin-based composites (D2332, D2335), and posterior resin-
based composites (D2392, D2393) provided from June 11, 2021, to December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics (D6240 and D6245) and a core build-up (D2950) 
provided by a participating provider on March 22, 2022. 
 
You asked the Plan to pay for pontics and a core build-up. You say that you cannot afford this bill. The Plan 
denied your request. The Plan says the rendered 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 pay for pontics 
(D6240 and D6245) and a core build-up (D2950) provided by a participating provider on March 22, 2022.