Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested service because you 
are having difficulty eating and speaking. 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 maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) but is limited to one procedure per 60 floating months. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered maxillary partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5213) on September 21, 2018, therefore, this benefit was exhausted. Therefore, we decided that the Plan 
does not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q0092 and R0070 rendered on September 
6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code Q0092 and R0070 remain 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment 
 
 
 HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that on September 6, 2022, the patient 
had a one view chest x-ray; however, there was no description of a portable technique for the exam, and no 
documentation of transportation and setup of a portable x-ray unit was described. Thus, Q0092 and R0070 are 
not documented in the records submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes Q0092 and R0070 rendered on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like approval for these services. 
The Plan denied your request. The Plan says dental services from an out-of-network provider are not covered 
by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational due to the wide range of efficacy 
reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable and 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that your doctor referred a monitor 
that goes on your arm and stated this monitor would work better for you. The Plan denied your request. The 
Plan says you do 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 you do  not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve veneer bonding (D2960). 
 
You asked the Plan to pre-approve veneer bonding. You say that this should be covered. The Plan denied your 
request. The Plan says this procedure 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. 
 
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 
veneer bonding (D2960).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on November 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the criteria is not met as the patient was ultimately discharged with no risk or threat to life. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records did not support 
medical decision making of high complexity. The records did not support that the presenting problems were of 
high severity, posing an immediate significant threat to life and function. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99285) rendered on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial frenectomy (D7961). 
 
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 they approved two alveoloplasty not in conjunction with extractions (D7320 x2) 
already, so youve met your frequency limitations. 
 
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 met. Therefore, we decided that the Plan does not 
have to pre-approve labial frenectomy (D7961).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with bed rails. 
 
You asked the Plan to pre-approve a semi-electric hospital bed with bed rails. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested item. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed with bed 
rails. Our reviewer says that the documentation does not support that the requested item is medically reasonable 
or necessary. Our physician reviewer found the enrollee has diagnoses of atrial fibrillation, gastro-esophageal 
reflux disease without esophagitis, diabetes, hypertension and urinary incontinence with a history of frequent 
falls, a hip fracture and dizziness. The documentation does not support that the enrollee's condition requires 
position of the body in ways not feasible in an ordinary bed. The documentation does not support that the 
enrollee requires frequent changes in body position or immediate changes in body position. The documentation 
does not support that the enrollee's condition requires special attachments that cannot be fixed and used on an 
ordinary bed. Therefore, the enrollee does not meet criteria for the requested item. 
 
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 semi-electric hospital bed with bed rails have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a semi-electric hospital bed with bed rails.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony (D7240). 
 
You asked the Plan to pre-approve the removal of impacted tooth - completely bony (D7240). You say that the 
dentist referred you to have this service done by a dental surgeon. You also say that the tooth is impacted and is 
causing infections. 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 pre-approve 
removal of impacted tooth - completely bony (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because anesthesia 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 
anesthesia (D9222 and D9223).
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 have pain with walking in a regular shoe 
and you need the special insets. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestlye Libre 3. 
 
You asked the Plan to pre-approve a Freestlye Libre 3. You say that this sensor is medically necessary. The 
Plan denied your request. The Plan says the requested device is not a covered Medicare 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 Freestlye Libre 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment support crown (D6508), a bone graft (D6104), 
an implant placement (D6010), and a custom abutment (D6057). 
 
You asked the Plan to pay for an abutment support crown, a bone graft, an implant placement, and a custom 
abutment. You say that this dental work is medically necessary. 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 pay for an abutment support crown (D6508), a bone graft (D6104), an implant placement (D6010), and a custom 
abutment (D6057).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99233 provided from March 3, 2022, to March 7, 2022. 
 
You asked the Plan to pay for the services at issue. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that they would have overturned their decision at the Plan level if they had 
processed it within the required timeframe. 
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for code 99233 provided from March 3, 2022, to March 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve the Freestyle Libre 2. 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. Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with extractions-
four or more teeth or tooth spaces, per quadrant (D7320). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
alveoloplasty not in conjunction with extractions-four or more teeth or tooth spaces, per quadrant (D7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) for tooth #10. 
 
You asked the Plan to pay for the dental services. You say that you would like this covered. 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 with the approval of D2750 for tooth #5, 
#30, and #9. Therefore, we decided that the Plan does not have to pay for a crown (D2750) for tooth #10.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.