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

 
We decided that the Plan does not have to pre-approve bone grafts at the time of implant placement  
(D6104 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone grafts 
at the time of implant placement (D6104 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia services during an epidural steroid injection 
procedure. 
 
You asked the Plan to pre-approve anesthesia services during an epidural steroid injection procedure. You say 
that you have always done this procedure with anesthesia because it is too painful when the needle and the 
liquid inserted is in you. You say that in the past when they have tried to do the injection without the anesthesia 
you have moved due to the pain causing them to have to reinsert the needle, which is far more painful. The 
Plan denied your request. The Plan says anesthesia during an epidural steroid injection procedure does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that use of Moderate or Deep Sedation, General 
Anesthesia, and Monitored Anesthesia Care is usually unnecessary or rarely indicated for these procedures and 
therefore not considered medically reasonable and 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 anesthesia services during an epidural 
steroid injection procedure. Our reviewer says that anesthesia during an epidural steroid injection procedure is 
not medically necessary. Our physician reviewer found there needs to be a medical reason that the enrollee 
needs to be asleep in order to be approved for coverage. There is no specific clinical rationale for the use of 
anesthesia for an epidural steroid injection. The review has determined that the requested anesthesia does not meet the Medicare LCD coverage 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 anesthesia services during an epidural steroid injection procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve anesthesia services during an epidural 
steroid injection procedure.
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 May 18, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not want the emergency medical services (EMS) called. You also say that you came around when EMS arrived 
and since you did not call for them you should not be responsible for the charge. 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 May 18, 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 May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show improvement with conservative therapy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document failure of a four-week trial of conservative 
therapy. Conservative therapy in this case has resulted in a 16.8 cm improvement in her left leg swelling and a 
6.25 cm improvement in her right leg swelling with the latest medical note stating: "Patient reported that she 
feels she is able to manage lymphedema at home independently with continued compliance with exercise, 
compression wear, and self pumping techniques." 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) acetaminophen and cough drops 
purchased on October 22, 2022. 
 
You asked the Plan to pay for OTC drugs. You say that the only reason you made this purchase was because 
the Plan representative told you that you had an allotment of $100 for OTC medications. The Plan denied your 
request. The Plan says these items are not covered by the Plan's OTC benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The Plan offers 
an OTC benefit that goes beyond Medicare coverage. For that reason, the Plans rules apply to this case. The 
Plan covers up to $100 per calendar year for OTC medications, restricted to aspirin, calcium, and calcium-
Vitamin D. 
 
Although the Plan offers an OTC medication benefit, the medications you purchased are not covered by this 
benefit because they are not aspirin, calcium, or calcium-Vitamin D combination. Therefore, we decided that 
the Plan does not have to pay for over-the-counter (OTC) acetaminophen and cough drops purchased on 
October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as they were not 
requested on the basis of a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, the acupuncture services in this case were not requested on the basis of a diagnosis for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. You say that your dentist recommended this for you. The 
Plan denied your request. The Plan says the requested dental 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 pre-approve an 
occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on October 31, 2022. 
 
You asked the Plan to pay for code D7953. You say that this service should qualify as appropriate and 
necessary. 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 pay for a bone 
replacement graft for ridge preservation - per site (D7953) provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services (97802, 97803) 
provided from July 5, 2022, October 21, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you were advised the provider 
was in-network. You say that your visits take place via telehealth. You also say that you were not aware that 
the provider would bill with an out-of-network address. The Plan denied your request. The Plan says you do 
not have a qualifying condition and therefore the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pay for the medical nutrition therapy services (97802, 97803) provided from July 5, 2022, October 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for May 6, 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 procedure code 99292 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of 
additional 30 minutes of critical care services spent with the enrollee. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99292 billed for May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a pontic (D6242), and 
retainer crowns (D6752) for tooth #29, #30, and #31 provided on October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the prior dentist misdiagnosed you and should 
have done a filling or extraction. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation has already been exhausted. Also, the denial of payment for the pontic and retainer crowns is correct 
because they are not covered by the Plan. Also, it was verified that you were given the proper dental benefit 
coverage prior to the date of service. 
 
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 limited oral evaluation was exhausted on date of service June 14, 2022. The pontic 
and retainer crowns are not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation (D0140), a pontic (D6242), and retainer crowns (D6752) for tooth 
#29, #30, and #31 provided on October 13, 2022.  
 
Your complaint about you experience with the contracted providers 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost share amount for the consultation (99202) provided on 
December 15, 2022. 
 
You asked the Plan waive the cost share amount for the specialist visit. You say that your biopsy records were 
never received at this office. You say that you were advised to keep your appointment despite this. You also 
say that you should not have to pay for this appointment that was a waste of time. 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 $35 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $35 copayment for the specialist visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits 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 
waive the cost share amount for the consultation (99202) provided on December 15, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
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 a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found conservative measures 
have been unsuccessful, a CT scan of the sinuses is in order and should be approved. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a carotid ultrasound and computed tomography angiography 
(CTA) of the aorta and runoff. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not indicated for neck discomfort. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in terms of the carotid ultrasound, the last exam was in 2015, with the results unknown. The enrollee 
has neck pain and history of peripheral vascular disease (PVD). Plus, there is A Fib and has discontinued 
Coumadin. The enrollee has at least two comorbidities predisposing her to carotid disease, and with the new 
onset of neck pain and known peripheral artery disease, the ultrasound is reasonable. In terms of the CTA, the 
enrollee had a CTA with runoff and positive results on August 31, 2022. The persistent leg pain and the 
discontinuation of her anticoagulation in the face of known abnormal findings on prior CTA mean the 
requested CTA is reasonable given her pain and known PVD and A-fib. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a carotid ultrasound and computed tomography angiography (CTA) of the aorta and runoff.  
 
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 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre Sensor. You say that the enrollee has difficulty obtaining 
blood from her hands and a fear of needles. 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 injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and an adjunctive pre-
diagnostic test (D0150, D0431) provided on November 8, 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 your benefit for the comprehensive oral evaluation 
has already been exhausted. Coverage for the adjunctive pre-diagnostic test 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. 
 
 
  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 March 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and an adjunctive 
pre-diagnostic test (D0150, D0431) provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase of the fitness benefit reimbursement. 
 
You asked the Plan to pre-approve an increase of the fitness benefit reimbursement. You say that you are 
requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request 
exceeds the allowable benefit for this service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 The Plans rules for coverage of gym benefits have not been met because your request for an increase in  
reimbursement from $200 to $372 exceeds the allowable benefit for this service. The Plan contract states that 
you pay all charges over $200 per calendar year. Therefore, we decided that the Plan does not have to pre-
approve an increase of the fitness benefit reimbursement.