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

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide Test Strips. 
 
You asked the Plan to pre-approve the test strips. The Plan denied your request. The Plan says these test strips 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the test strips. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that  the enrollee is a 65-year-old female with diabetes maintained on medial therapy. There is no 
specific clinical rationale for the requested Accu-Chek Guide Test Strips. The Accu-Chek Guide Test Strips at 
issue in this case are 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 the test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Accu-Chek Guide Test Strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on April 13, 2022. 
 
You asked the Plan to pay for intraoral - complete series of radiographic images (D0210). You say that the 
provider did not submit the correct charges to the plan. The Plan denied your request. The Plan says the service 
is covered but limitations apply. 
 
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. Supplemental Dental Benefit 
includes intraoral x-rays  one procedure code per calendar year. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered intraoral  
complete series of radiographic images on April 6, 2022. Therefore, these benefits were exhausted as of April 
6, 2022. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic 
images (D0210) provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital bed provided on May 16, 2022. 
 
You asked the Plan to waive the coinsurance for a hospital bed. You say that you should not be responsible to 
pay this. 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 durable medical equipment (DME) and related supplies. 
 
 
 
 
 
 
 
 You have been asked to pay 20% coinsurance for a hospital bed. This item/service falls within the durable 
medical equipment (DME) and related supplies 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 a hospital bed provided on May 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that your provider doubled your insulin units 
and needs to make sure you are testing accurately. The request CGM is necessary. The Plan denied your 
request. The Plan says you do not meet coverage criteria for approval of the requested supplies. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
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 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 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 you do not have documented skilled nursing or documented skilled therapy needs. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs can, as a practical matter, be provided at a lower level of care. 
 
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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiation therapy practitioner visits provided from February 1, 2022, to 
April 30, 2022. 
 
You asked the Plan to pay for radiation therapy services. You say that these visits were all part of your 
radiation treatments and should be inclusive. The Plan denied your request. The Plan says that the denial of 
payment for these services is correct. 
 
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. The Plan did not provide any detail about the denied claims. The Plan did not 
provide any rationale or evidence to support their decision to deny payment for these services. Without this 
information, the Plan has not shown that its decision to deny payment for these services is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for radiation therapy practitioner 
visits provided from February 1, 2022, to April 30, 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 pre-approve sacral nerve stimulator implantation for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee has documented benign prostatic hyperplasia with 
obstruction as well as neurogenic bladder with hyporeflexia. 
 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The records show 
that the enrollee has neurologic disease and neurogenic bladder which excludes sacral nerve stimulator 
implantation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these sevices have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral nerve stimulator implantation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita (CPT code Q4180). 
 
You asked the Plan to pre-approve the skin graft. You say that you do not want the enrollee to lose their foot. 
The Plan denied your request. The Plan says the request for application of skin substitutes is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the skin graft. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show that there has been an assessment of the enrollee's blood flow and 
correction of any amenable vascular problems for arterial ulcers. The records also show persistence of 
osteomyelitis and poorly controlled diabetes. The review has determined that the items/services at issue in this 
case are 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 the skin graft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Revita (CPT code Q4180).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical mitral valve replacement (MVR). 
 
You asked the Plan to pre-approve MVR services. You say that this procedure is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
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 MVR services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical appropriateness and necessity for MVR in the setting of the enrollees 
symptoms coupled with evidence of mitral regurgitation. Imaging has assessed the mitral regurgitation as 
severe; however, characterization of the valve regurgitation is not documented in sufficient detail to assess 
whether criteria for valve replacement are met. As such, the documentation would not confirm that the mitral 
regurgitation is of sufficient severity to warrant valve replacement. As a result, at this time MVR would not be 
considered medically reasonable and necessary in this enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MVR services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical mitral valve replacement (MVR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 7, 
2022, to May 6, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services are coverable under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee did not receive daily skilled care. 
 
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 pay for SNF care. Our reviewer says that the SNF 
care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 pay for the skilled nursing facility (SNF) care provided from April 7, 2022, to May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99050 billed for date of service March 29, 
2021. 
 
You asked the Plan to pay for procedure code 99050. You say that the attached documentation should be 
reviewed, and the claim reprocessed for maximum reimbursement. The Plan denied your request. The Plan 
says procedure code 99050 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
  We find that procedure code 99050 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99050 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99050 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99050 billed for date of service March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950), 
and crown - porcelain/ceramic (D2740) on tooth 29, provided on July 12, 2022. 
 
You asked the Plan to pay for a core buildup, including any pins when required (D2950), and crown - 
porcelain/ceramic (D2740) on tooth 29. You say that you were advised that the service was approved before 
the service was done. The Plan denied your request. The Plan says these services are not covered under the 
benefit 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 a core 
buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) on tooth 29, 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete mandibular denture (D5751) provided on 
June 21, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for a reline complete mandibular denture (D5751) provided on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this is the correct modifier to use per CMS 
guidelines and medical records are attached for review. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the complete lower denture adjustment 
(D5411), the complete upper denture adjustment (D5410), the reline complete upper denture (D5750), and the 
reline complete lower denture (D5751) provided on February 9, 2022 and February 28, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under the 
enrollees contractual policy or by Medicare. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
complete lower denture adjustment (D5411), the complete upper denture adjustment (D5410), the reline 
complete upper denture (D5750), and the reline complete lower denture (D5751) provided on February 9, 2022 
and February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 18, 2022, to June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the services requested 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 the dental 
services on May 18, 2022, to June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 15, 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 the 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 15, 2022.