Persius/hicric huggingface dataset:
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 admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 only require short-term additional acute care services (including weaning) that can safely be performed at the current facility until appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility is recommended.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transport package (CPT code K0108). 
 
You asked the Plan to pre-approve the transport package. You say that you have a history of spinal stenosis and 
chronic sacral wound requiring wheelchair to be able to participate in routine daily activities. You state you do have a power wheelchair and would like to obtain a rack so that this can be attached to your vehicle. The Plan 
denied your request. The Plan says the requested transport package (K0108) is for use outside of the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Furthermore, the 
rules say that Medicare will pay for durable medical equipment that is needed for use in the home. Your home 
may be a dwelling, an apartment, a relatives home, a home for the aged, or some other type of institution. 
However, an institution may not be considered your home if it is an acute hospital or a skilled nursing facility 
(SNF). Therefore, we decided that the Plan does not have to pre-approve the transport package (CPT code 
K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide/analgesia (D9230). 
 
You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. The Plan denied your request. The 
Plan says this service is not included on the enrollee's 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 the 
inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), cone beam computed tomography (CT) capture and 
interpretation with limited field of view - less than one whole jaw (D0364), and sales tax (D9985) provided 
March 15, 2022. 
 
You asked the Plan to pay for the limited oral exam, periapical x-ray, cone beam CT scan and sales tax. You 
say that these services were recommended as a follow up to a sinus infection. The Plan denied your request. 
The Plan says you have exceeded the frequency limit for the periapical x-ray. The remaining services are 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 Plan's coverage rules apply in this case. The Plan covers the periapical 
x-ray once per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a periapical x-ray 
was previously covered on January 22, 2022. Based on this information, we decided that the Plan's frequency 
limit for coverage of the periapical x-ray has been exceeded. Though the Plan offers dental benefits in excess of 
Medicare coverage, the limited oral exam, cone beam CT scan and sales tax are not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused (D0140), intraoral - periapical first radiographic image (D0220), cone beam computed tomography 
(CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and sales tax 
(D9985) provided March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve color touch screen remote and a color touch screen 
remote/joystick. 
 
You asked the Plan to pre-approve color touch screen remote and a color touch screen remote/joystick. You say 
that you disagree with the plan's denial. The Plan denied your request. The Plan says the requested items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve color touch screen remote and a color touch screen 
remote/joystick.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 8, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that your provider contacted the plan prior to 
services, and you were told that surgical extractions are covered by your plan at 50%. The Plan denied your 
request. The Plan says your benefit does not cover surgical extractions. The Plan also reviewed their call logs 
and found that no misinformation was provided on their end. 
 
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 
surgical extraction (D7210) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided January 27, 2022. 
 
You asked the Plan to pay for the core buildup. You say that the Plan's system has your dental plan wrong in 
the system. The Plan denied your request. The Plan says your claims from this date of service have been 
reprocessed, however the core buildup 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 pay for the core 
buildup, including any pins when required (D2950) provided January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustment of gastric band coded S2083 and the 
fluoroscopic guidance services coded 77002 provided on September 21, 2021. 
 You asked the Plan to pay for the adjustment of gastric band and the fluoroscopic guidance services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not payable. 
 
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 find that CPT code S2083 is not supported 
in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is 
not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. In 
this case, we have confirmed that code 77002 is a column II code to column I code 74240. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the adjustment of 
gastric band coded S2083 and the fluoroscopic guidance services coded 77002 provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown - porcelain fused to high noble metal 
(D6750) and pontic - porcelain fused to high noble metal (D6240) provided December 16, 2021. 
 
You asked the Plan to pay for the retainer crown and pontic. You say that you would like these services 
covered. The Plan denied your request. The Plan says these services are 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 Plan's 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 
retainer crown - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal 
(D6240) provided December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation  post-operative office visit (D0171) 
provided January 28, 2022. 
 
You asked the Plan to pay for the post-operative office visit. You say that this service was necessary to ensure 
you did not have a viral infection or bleeding following a tooth extraction. 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 pay for the re-
evaluation  post-operative office visit (D0171) provided January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral radiographic 
images received on February 23, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral radiographic images. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received 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. Review of the file shows that you previously received a 
comprehensive oral evaluation and full mouth x-rays in July 2020. Three calendar years had not passed since 
you previously received the comprehensive evaluation and five calendar years had not passed since you 
previously received the full mouth x-rays. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and intraoral radiographic images received on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride (D1204) prophylaxis (D1110) 
bitewings - four films (D0274) oral cancer evaluation (D0120) provided February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of $117.00 
for services provided. The Plan denied your request. The Plan says services are not covered if rendered by 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.  
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 topical 
application of fluoride (D1204) prophylaxis (D1110) bitewings - four films (D0274) oral cancer evaluation 
(D0120) provided February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal cleanings (D4910) provided on April 20, 2021, 
and October 20, 2021. 
 
You asked the Plan to pay for periodontal cleanings. You say that your annual notice of changes still shows 
that you should only be responsible for a $15 copayment for preventative dental care, and you do not 
understand why these services are not covered. The Plan denied your request. The Plan says Periodontal 
cleanings (also called periodontal maintenance) are 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 Plan's 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. Please also note that the annual notice of changes states that the benefit 
covers, "two cleanings (excluding periodontal cleanings) per calendar year" under both the column for 2021 
and the column for 2022. Therefore, we decided that the Plan does not have to pay for periodontal cleanings 
(D4910) provided on April 20, 2021, and October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on January 29, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service is not supported in the record. 
 
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Based on this information, we decided that Medicare rules for coverage of 
critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 
hour (99291) provided on January 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on November 29, 2021. 
 
You asked the Plan to pay for the periodic exam. You say that you were told these services would be covered 
as you only had one cleaning this year, and you didn't know that the exam you had in June counted. The Plan 
denied your request. The Plan says your benefit covers two oral exams per calendar year. You previously had 
oral exams on July 28, 2021, and June 11, 2021, which were covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit 
covers two oral exams every year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
oral exam is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the periodic oral exam (D0120) provided on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sleep study provided on February 14, 
2022. 
 
You asked the Plan to waive the copayment for a sleep study. You say that you were told there was no 
copayment for sleep studies. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $250 
copayment for Medicare-covered sleep studies and stress tests.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$250 copayment for a sleep study. A sleep study 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 a sleep 
study provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item 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 MyoPro Motion G Orthotic device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has right hemiparesis from a cerebrovascular accident in 2017. 
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes in stroke enrollees. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
Therefore, the enrollee does not meet criteria for the requested item.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments (D9630 x 3) provided on February 
9, 2022. 
 
You asked the Plan to pay for the drugs or medicaments. You say that the services were wrongly denied. You 
also say that this should be covered. The Plan denied your request. The Plan says the services denied correctly. 
 
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 drugs or medicaments are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs 
or medicaments (D9630 x 3) provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) sensor (K0554) 
and supplies (K0553). 
 
You asked the Plan to pre-approve the CGM sensor and supplies. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the member 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. 
 
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 the CGM 
sensor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) sensor (K0554) and supplies (K0553).