Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2021, to 
October 12, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient hospital services was not filed until January 13, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services provided on October 4, 2021, to 
October 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 14, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that one of the 
aides at the assisted living facility called 911 thinking you were having a stroke. You also say that they were 
not aware that you would be charged in full if the ambulance did not transport you to the hospital. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 9, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered, but you feel like 
you were billed incorrectly for some services. 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. This benefit includes the 
requested periodontal maintenance (D4910) but is limited to three procedures per plan year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D4910 on January 25, 2022, May 3, 2022, and August 3, 2022. Therefore, these 
benefits were exhausted as of August 3, 2022. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need an orthopedic shoe repair. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia  first 15 minutes (D9222), 
and each subsequent 15 minute increment (D9223) provided on December 27, 2022. 
 
You asked the Plan to pay for deep sedation/general anesthesia. You say that you don't understand how anyone 
could receive extractions without anesthesia. 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 Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep 
sedation/general anesthesia  first 15 minutes (D9222), and each subsequent 15 minute increment (D9223) 
provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on April 8, 2022. 
 
You asked the Plan to pay for dental services. You say that the Plan documentation you have, does not show 
that the requested service is not covered. 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. Consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) is not covered 
under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9310 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says this CGM is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth, or exposed root (elevation and/or 
forceps removal) (D7140) provided on November 9, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told the service you received is covered 
under your plan. 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 (elevation and/or forceps removal) (D7140) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7140 is 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 (elevation and/or forceps removal) (D7140) provided on November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services received December 5, 2022, to December 7, 
2022, minus any cost share requirement. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the claim was billed with an incorrect type of bill. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the inpatient services by a contract provider. The file does not show that the Plan provided 
notice that the inpatient services would not be covered. You should not be held responsible for billing issues 
from a participating provider. Under Medicare rules, this means the inpatient services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the inpatient services received December 5, 
2022, to December 7, 2022, minus any cost share requirement.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay inpatient services provided on November 25, 2022. 
 
You asked the Plan to pay inpatient services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that prior authorization is not a valid denial reason. 
 
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.  Therefore, we decided that the Plan has to pay inpatient services provided on 
November 25, 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 pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. 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 from your provider 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: 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 requested CGM is medically necessary. 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 continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
a resin-based composite (D2392), and scaling in presence of gingival inflammation (D4346) for tooth #19 
provided by an out-of-network provider on December 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the dental office said that the Plan should 
have covered more of your 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. Also, the denial of payment for the scaling in presence of gingival inflammation is correct, because it 
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. 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. The 
scaling in presence of gingival inflammation is not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), a 
resin-based composite (D2392), and scaling in presence of gingival inflammation (D4346) for tooth #19 
provided by an out-of-network provider on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused (D6750 x 2), pontic- 
porcelain fused (D6240) and retainer crown- full cast (D6792). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have already been approved one pontic for tooth #30 and one retainer crown 
for tooth #29 so the rest will be 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown - porcelain fused (D6750 x 2), pontic- porcelain fused (D6240) and 
retainer crown- full cast (D6792).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through a network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan provides coverage for hearing aids only when 
purchased from a network provider. However, your request in this case is to purchase hearing aids from an out-
of-network provider. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be 
rendered 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 surgical placement of the implant bodies (D6010) and 
extractions (D7140) for tooth #7, #12, #13, and #14 provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement for the dental 
services. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 on February 3, 2021, the Plan paid $375 for dental services. On June 23, 2021, the Plan paid $375 for 
dental services. For the year of 2021 the Plan paid $750 ($375 paid + $375 paid) for dental services; therefore, 
your annual dental benefit for the year of 2021 was exhausted on the date of service of June 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the surgical placement of the implant bodies 
(D6010) and extractions (D7140) for tooth #7, #12, #13, and #14 provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of the 
requested services as you do not have chronic low back pain. 
 
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 Plan has stated that you do not meet criteria for coverage of the 
requested services as you do not have chronic low back pain. However, the Plan provides supplemental 
coverage for acupuncture services under the wellness allowance benefit policy. The Plan has not substantiated 
their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-approve 
acupuncture treatments.  
 
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 pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on June 2, 2022. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported. 
 
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, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; therefore, code 99152 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on June 2, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
You asked the Plan to pre-approve PTA. 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 PTA is covered when used under certain conditions. 
 
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 PTA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found guidelines are clear that such a procedure 
would be authorized only if there were accompanying symptoms or if the lesion narrowing were 80% or more. 
In their absence, PTA and stent placement would not be considered 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 PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transluminal angioplasty (PTA).