Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure has not been proven helpful for the enrollee's condition. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe 
and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for 
the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic consultation with a dentist/physician other 
than the requesting dentist/physician (D9310) and an incomplete root canal of an inoperable or fractured tooth 
(D3332). 
 
You asked the Plan to pre-approve a consultation and incomplete root canal. You say that these are necessary 
follow-up services after your root canal. The Plan denied your request. The Plan says the diagnostic 
consultation is only allowed once every 3 months, and you previously had this service provided on June 10, 
2022. In addition, an incomplete root canal is not covered by your dental 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 incomplete root canal is 
not among those covered under this benefit. For services that are covered under this benefit, certain limitations apply. The record shows that your benefit for the requested diagnostic consultation was exhausted on June 10, 
2022. This service is only covered once every three months, and three months have not elapsed since this date. 
Therefore, we decided that the Plan does not have to pre-approve a diagnostic consultation with a 
dentist/physician other than the requesting dentist/physician (D9310) and an incomplete root canal of an 
inoperable or fractured tooth (D3332).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 11, 
2022, by an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were rendered in good 
faith and medically necessary. We depend upon the office staff to verify eligibility and to obtain the proper 
authorization from the enrollee's Plan. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
January 11, 2022, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 
28, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the services were rendered to the enrollee in good 
faith. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 
28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. The Plan denied your request. The Plan says 
the Vertiflex Superion device is experimental and investigational. 
 
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 Vertiflex Superion device. Our 
reviewer says that the Vertiflex Superion device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental. 
 
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 Vertiflex Superion device have not been met.  
 
 
 
  
 
 
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic (D6252 x2). 
 
You asked the Plan to pay for pontic. You say that the services at issue were medically necessary. The Plan 
denied your request. The Plan says the 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pontic 
(D6252 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D6740, D6245) 
 
You asked the Plan to pre-approve the porcelain/ceramic crowns. You say that the services should be covered 
as you disagree with the denial and the services are medically necessary. 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 pre-approve 
porcelain/ceramic crowns (D6740, D6245)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor (CGM) sensor 
(K0553) provided on November 11, 2021. 
 
You asked the Plan to pay for a Freestyle Libre CGM sensor. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for CGMs and related 
supplies have 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 
Freestyle Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pay for a 
Freestyle Libre continuous glucose monitor (CGM) sensor (K0553) provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0020 billed for date of service September 8, 
2021. 
 
You asked the Plan to pay for procedure code S0020. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
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 S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S0020 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0020 billed for date of service September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you should not owe this amount. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $150 
copayment for all other diagnostic and nuclear medicine radiological services. 
 
You have been asked to pay $150 copayment for MRI. MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and 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 copayment for 
MRI provided on March 1, 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 
(A0998) provided on March 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
this service should be covered. The Plan denied your request. The Plan says you were evaluated and treated, 
but there was no transport. 
 
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 March 15, 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 (A0998) provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 5, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a covered 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene testing which included the FANCC gene is statutorily 
excluded. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on January 5, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the upper partial denture (D5213) provided on 
February 23, 2022, by the out-of-network provider. 
 
You asked the Plan to reimburse you for the dental item. You say that there has been so much misinformation 
give back and forth to you. You say that you have been told the provider is out-of-network, then in-network. 
You say that you have been seeing this provider for several years. You also say that an exception should be 
made due to all of the confusion. 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 upper partial denture from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the upper partial denture is not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to reimburse you for the upper partial denture (D5213) provided on February 23, 2022, by the out-of-network 
provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy, occupational therapy, and speech therapy 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON therapies. You say that having consolidated care is incredibly 
important for patients with this diagnosis as it optimizes health care delivery and prolongs survival. The Plan 
denied your request. The Plan says that services can be provided by an in-network provider. 
 
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 OON therapies. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the available clinical documentation supports that the enrollee in this case requires 
specialized speech therapy, physical therapy, and occupational therapy in a setting that provides a 
multidisciplinary care team focused on the management of the enrollees medical condition. Such out-of-
network services are medically reasonable and necessary for this enrollee due to the relentlessly progressive 
nature of the primary diagnosis, and the requirement for coordinated care to optimize their outcome.  
The plan has not sufficiently demonstrated that equivalent coordinated multidisciplinary services are available 
in-network. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON therapies have been met. Therefore, we decided that the Plan has to pre-
approve physical therapy, occupational therapy, and speech therapy provided by an out-of-network (OON) 
provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
complete series of radiographic images (D0210) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the services were 
performed again. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 24, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
complete series of radiographic images (D0210) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crowns. You say that you were told 
your insurance would cover the procedure. The Plan denied your request. The Plan says these services are not 
covered under your 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 pre-approve 
implant supported porcelain/ceramic crowns (D6065).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of thorax (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee needs a follow up. You say that the 
enrollee had an abnormal chest CT. You also say that the enrollee has lung problems. The Plan denied your 
request. The Plan says the provided documentation does not indicate a clinical change in medical condition 
since the previous CT was performed. The Plan also says that the requested CT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the provided notes did not clearly 
explain the reason for the repeat CT so soon after a prior CT a few months prior. The reviewer found that the 
enrollee was stable, did not have significant changes in clinical presentation to justify CT at this time. 
Therefore, the request for CT chest will be considered not medically necessary based on the provided 
documentation. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) of thorax (71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment - complete (D9952). 
 
You asked the Plan to pre-approve an occlusal adjustment. You say that you would like this service covered. 
The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve an 
occlusal adjustment - complete (D9952).