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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents, cervical (72141). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is still having severe pain that is 
radiating. The Plan denied your request. The Plan says there was not adequate time to see how the enrollee 
responded to the provided treatments before the MRI of the neck was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the enrollee has a 
normal neuro exam and no right arm parasthesia. Neck has improved with over-the-counter medications. There 
is no right arm weakness or reflex abnormality. Physical therapy has not yet been attempted. With no red flags 
and no attempt at physical therapy, the medical necessity of the requested MRI cervical spine has not yet been 
demonstrated. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and contents, cervical (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a dental extraction (D7210), surgical placement of an 
implant (D6010), and bone replacement graft for ridge preservation (D7953) provided on June 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the enrollee overpaid for services obtained 
from a provider that was deceptive regarding network status. The Plan denied your request. The Plan says 
enrollees are responsible for any charged amount above the Plans cost-sharing amount when services are 
received from an out-of-network provider.  
 
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. Since 
codes D6010 and D7953 are not listed as covered services, you are responsible for the full charged amount of 
these procedures. For the extraction (D7210), you are responsible for a 50% coinsurance. Therefore, we 
decided that the Plan does not have to pay more for a dental extraction (D7210), surgical placement of an 
implant (D6010), and bone replacement graft for ridge preservation (D7953) provided on June 20, 2022.  
 
Your complaint about being misled about the providers network status is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. The Plan states that 
this has already been addressed, therefore, please contact the Plan for further information. 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 the Freestyle Libre 2 (E0607). 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that you are diabetic, and you need this 
product. Your primary doctor approved for you to get this product. The Plan denied your request. The Plan says 
the enrollee does not meet all of the criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 2 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 (E0607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and related accessories and features. 
 You asked the Plan to pre-approve a Group 3 power wheelchair with related accessories. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for the requested items 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 a Group 3 power wheelchair with 
related accessories. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the provided records do not support that the enrollee 
is high-risk for skin breakdown as the enrollee can independently transfer, that the enrollee has a history of 
pressure ulcer(s) or has had skin flap surgery. Records do not document that the enrollee performs bladder self-
catheterization and is unable to transfer independently or that the enrollee has increased muscle tone or 
spasticity. No need is documented for a wheelchair-mounted ventilator. 
 
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 Group 3 power wheelchair with related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with 
single power option (K0856) and related accessories and features.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a bone chip that was sticking inside of 
your cheek. You also say it was causing a lot of pain. 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. The Plan rules say that this 
service is limited to one procedure per plan year. 
 
 
  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 June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and improving and should require short-term additional acute care services that can be safely provided at the current facility until more stable for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device surgery (22869). 
 
You asked the Plan to pre-approve the vertiflex device surgery. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is experimental. 
 
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 device surgery. Our 
reviewer says that the requested service is not medically necessary or reasonable. Our physician reviewer found 
this service is experimental and more research is needed to show safety and efficacy. 
 
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 device surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the vertiflex device surgery (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee joint replacement surgery and associated 
procedure to be provided by an OON provider. 
 
You asked the Plan to pre-approve the knee joint replacement surgery and associated procedure. The Plan 
denied your request. The Plan says this service is available by a provider in your network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a knee joint replacement surgery and associated procedure to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the detailed and extensive oral 
evaluation - problem focused, by report (D0160) provided on April 19, 2022, and the  extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), and intraoral - periapical first 
radiographic image (D0220) provided on May 3, 2022. 
 
You asked the Plan to provide additional payment for the detailed and extensive oral exam, dental extraction, 
nitrous oxide/analgesia and periapical x-ray. You say that you chose to see a dentist who has an established office. The Plan denied your request. The Plan says you have exhausted your dental allowance, and no further 
payment is due. 
 
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 Plan covers the detailed 
and extensive oral exam, dental extraction, nitrous oxide/analgesia and periapical x-ray up to a $1,000 
allowance every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full dental 
allowance was applied to your claims on May 3, 2022. Therefore, we decided that the Plan does not have to 
provide additional payment for the detailed and extensive oral evaluation - problem focused, by report (D0160) 
provided on April 19, 2022, and the  extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210), inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230), and intraoral - periapical first radiographic image (D0220) provided on 
May 3, 2022.  
 
Your complaint about the quality of the Plans list of network dentist 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Remicade (J1745). 
 
You asked the Plan to pre-approve Remicade. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says the request 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 Remicade. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that you have pulmonary (lung) sarcoidosis. The record provided does not indicate that you have remained 
symptomatic despite treatment for 3 or more months with steroids (10 mg per day or more) and 
immunosuppressants (such as azathioprine, cyclophosphamide or methotrexate) or that you have a 
contraindication or intolerance to one immunosuppressant (such as azathioprine, cyclophosphamide, or 
methotrexate). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Remicade (J1745).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 27, 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 May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bone replacement graft for ridge preservation - per site (D7953) and 
prefabricated abutment  includes modification and placement (D6056) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that these services are not covered under your benefits. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. It is not clear in the plan contract that these services are excluded from coverage. The plan 
contract does not refer you to any other document for additional coverage information. Therefore, we decided 
that the Plan has to pay for the bone replacement graft for ridge preservation - per site (D7953) and 
prefabricated abutment  includes modification and placement (D6056) provided on June 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84165 billed for date of service March 10, 
2022. You asked the Plan to pay for procedure code 84165. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 84165 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 procedure code 84165 billed for date of 
service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 
periodontal scaling and root planing (D4341) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on May 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility visit provided on May 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for inpatient hospital stay provided from June 9, 2022, 
to June 10, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that this should be 
covered. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 for inpatient hospital care.  
 
The Plan says you must pay 20% coinsurance for inpatient hospital stay. Based on the Plan contract, however, 
you cannot be asked to pay more than $0 for inpatient hospital stay. Therefore, we decided that the Plan has to 
waive the coinsurance for inpatient hospital stay provided from June 9, 2022, to June 10, 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 pay for office visit provided on August 18, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care the enrollee receive from an out-of-network provider (a provider who is not part of our plan's network) will not be 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 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 office visit provided on August 18, 2022, by an out-of-network (OON) provider.