Persius/hicric huggingface dataset:
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 a CGM. 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. 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 a 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 Dexcom G6 receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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 and 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 Dexcom 
G6 receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, an 
outpatient diagnostic test and a specialist office visit provided on July 27, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs, an outpatient diagnostic test 
and a specialist office visit. You say that you disagree with the cost share. 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 a 20% 
coinsurance for Medicare Part B prescription drugs a $10 copayment for outpatient diagnostic tests/other outpatient diagnostic tests and a $50 copayment for physician/practitioner services/specialty care physician.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs, a $10 copayment for an 
outpatient diagnostic test and a $50 copayment t for a specialist office visit. The total allowed amount for the 
prescription drugs is $1,862.10. You are being asked to pay $372.42 ($1,862.10 x 20% = $372.42). The total 
amount you are being asked to pay for all services is $432.42. 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 Medicare Part B prescription drugs, an outpatient diagnostic test and a specialist office visit provided on 
July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on October 12, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says additional information was needed to review the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee hopes to avoid finger-stick testing. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration and guided tissue regeneration (D4265, D4266) provided on April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 biologic 
materials to aid in soft and osseous tissue regeneration and guided tissue regeneration (D4265, D4266) 
provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray, extraction, and a complicated suture 
(D0220, D7210, D7911) provided on October 11, 2022, 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. 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. Coverage for the complicated suture (D7911) denied correctly as it does not fall within your dental 
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 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 an intraoral x-ray, extraction, and a 
complicated suture (D0220, D7210, D7911) provided on October 11, 2022,
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) and 
the gingival irrigation-per quadrant (D4921 x 2) provided on November 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the localized 
delivery of antimicrobial agents (D4381) and the gingival irrigation-per quadrant (D4921 x 2) provided on 
November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for the lower 
right and the lower left quadrants and the extraction of an erupted tooth (D7140) for teeth numbers 2, 4, 5, 6, 7, 
and 8 provided from August 31, 2022, to October 4, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing (D4341) for the lower right and the lower 
left quadrants and the extraction of an erupted tooth (D7140) for teeth numbers 2, 4, 5, 6, 7, and 8. You say that 
you thought all dental plans included extractions. The Plan denied your request. The Plan says there is no 
coverage for these services. 
 
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 
periodontal scaling and root planing (D4341) for the lower right and the lower left quadrants and the extraction 
of an erupted tooth (D7140) for teeth numbers 2, 4, 5, 6, 7, and 8 provided from August 31, 2022, to October 4, 
2022.  
 
Your complaint about the potentially unprofessional service you received from the dental office is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
you need this home ventilator, it is lifesaving equipment. The Plan denied your request. The Plan says the 
requested device does not meet the requirements for approval. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD, and 
severe obesity. You have been on a trilogy home ventilator for the past year. No compliance data is provided. 
Pulmonary function tests show severe restrictive lung disease, with no evidence for airways obstruction or air 
trapping. Thus, this testing does not support the diagnosis of COPD. The arterial blood gas done while stable as 
an outpatient showed mild CO2 retention. The chronic hypoventilation is most likely related to a combination 
of obesity hypoventilation syndrome and severe restrictive lung disease. You would likely benefit from BiPAP 
during sleep as an outpatient. If you do have an element of COPD, AVAPS and backup rate could be provided 
via BiPAP. Medicare does not cover a home ventilator when used in BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedure of the nails provided on September 22, 
2022. 
 
You asked the Plan to pay for surgical procedure of the nails. You say that the records attached support the 
services provided The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgical procedure of the 
nails provided on September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on May 02, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the records attached support the 
services provided The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on May 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a cone beam computed 
tomography (D0367) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist already took films which you paid 
for before and now they are taking films over again. The Plan denied your request. The Plan says if you receive 
a service not listed in the dental benefits chart, you will have to pay the full cost. 
 
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 limited 
oral evaluation (D0140) and a cone beam computed tomography (D0367) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional hearing aid battery (V5266) provided on June 
7, 2022. 
 
You asked the Plan to pay for an additional hearing aid battery (V5266). You say that your appointment had 
gotten cancelled because the doctor is not a Plan hearing provider. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
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 they are the first 80 batteries per aid for non-rechargeable models. The benefit does not 
include or cover additional batteries.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of an additional hearing aid battery (V5266) have not been met. Therefore, we decided that the Plan 
does not have to pay for an additional hearing aid battery (V5266) provided on June 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for intensive outpatient services. 
 
You asked the Plan to provide coverage for intensive outpatient services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not covered by your Plan. Intensive 
outpatient services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of intensive outpatient services have been 
met. Specifically, there are no medical records provided for us to determine that Medicare coverage criteria 
have been met. Therefore, we decided that the Plan does not have to provide coverage for intensive outpatient 
services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429-GY) and 
ground mileage (A0425-GY) provided on September 14, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
called for an ambulance because you were having side-effects due to being over-prescribed a medication by a 
psychiatrist. You also say that before calling, you were advised to wait four days to see your regular 
psychiatrist, but you called the ambulance because you knew your problem was more serious. The Plan denied 
your request. The Plan says the criteria for approval have not been met. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency ambulance transportation (A0429-GY) and ground mileage (A0425-GY) have not 
been met. Specifically, the services at issue were billed with a GY modifier. The Plan cannot pay for the 
services as billed by the non-contracted provider. Based on this information, we decided that Medicare rules for 
coverage of the emergency ambulance transportation and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency ambulance transportation (A0429-GY) and 
ground mileage (A0425-GY) provided on September 14, 2022.
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 August 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
contacted emergency services after a fall. You also say that you did not receive any treatment from the 
ambulance personnel and there were no reported physical symptoms. 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 August 26, 2022. 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 August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a spinal electrical osteogenesis (bone growth) 
stimulator device. 
 
You asked the Plan to pre-approve spinal electrical osteogenesis stimulator device. You say that the enrollee 
meets criteria. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that a spinal osteogenesis stimulator is only covered if 
certain criteria are met. 
 
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 spinal electrical osteogenesis stimulator 
device. Our reviewer says that the enrollee does not meet the Medicare criteria for an osteogenesis device. Our 
physician reviewer found the records include a pre-operative visit note and a certificate of medical necessity, 
but do not include an operative report or other record documenting a multi-level spinal fusion procedure to 
meet 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 spinal electrical osteogenesis stimulator device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve use of a spinal electrical osteogenesis (bone growth) 
stimulator device.