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

 
We decided that the Plan has to pay for surgical services (procedure code 27630 and 27691) rendered on 
October 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes are not supported by the medical records submitted. 
 
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 
the denied codes is: 
 
CPT 27630: 
 
Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle 
 
CPT 27691: 
 
Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or 
posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon 
to midfoot or hindfoot) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records support that CPT 27630 
was a separate and distinct procedure from CPT 27687. The procedure details cite the medial edge of the 
gastrocnemius aponeurosis was encountered. The aponeurosis could not be separated from the underlying 
soleus fascia. Therefore, after making a longitudinal cut through this layer, the fibers of the soleus were 
dissected off the deep aspect of this layer. It was then released from medial to lateral under direct visualization. 
Then multiple areas of significant degeneration were sharply debrided. There were multiple old chronic-
appearing rents in the tendon, at which time it was obvious that there was approximately 3-4cm section of the 
tendon where nothing looked normal. Additionally, the records also support CPT 27691 as rendered in this 
case. The procedure details cite the FDC tendon was transferred to the distal stump of the posterior tibial 
tendon.  
 
We looked at this coder'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 pay for 
surgical services (procedure code 27630 and 27691) rendered on October 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flexible partial dentures to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need a new set of dentures and the 
previous provider you do not want to use again. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental benefits. Also, there are multiple in-
network provider available to provide the dental service requested. 
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the flexible 
partial dentures to be provided by an out-of-network provider.  
 
Your complaint about your experience with a previous provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and a retainer crown (D6740) for tooth 
#9 and #11. 
 
You asked the Plan to pre-approve the dental services. You say that the dentist needs to carry out the process 
for the work to be successful. The Plan denied your request. The Plan says your benefit for the requested items 
or services 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 the Plan pre-approved pontics (D6245) for tooth #7 and #8 and retainer crowns (D6740) for tooth #6 and 
#10 on February 15, 2023; therefore, the enrollees benefit for the requested items or services was exhausted on 
the date of approval of February 15, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6245) and a retainer crown (D6740) for tooth #9 and #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and retainer crowns (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that your bridge is broken. You say you are 
only left with metal in your mouth which is very uncomfortable and is sensitive to hot and cold food when 
eating. The Plan denied your request. The Plan says as stated in your dental benefit book, only services listed 
are covered by 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 a 
pontic (D6245) and retainer crowns (D6740).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a limited bilateral non-invasive physiologic study of the upper or lower 
extremity rendered on October 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the enrollee's diagnosis does not support medical necessity. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that due to age of the enrollee, the possibility of peripheral vascular disease was considered as the source 
of the pain. As such, bilateral ankle brachial index (ABI) was performed. This is a valid first screen when 
considering peripheral vascular disease as a possibility.  
 
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 pay for a 
limited bilateral non-invasive physiologic study of the upper or lower extremity rendered on October 7, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture  maxillary (D5110) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 June 15, 2020. Therefore, we decided that the Plan does not have to pre-approve complete denture  maxillary (D5110) and mandibular 
partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you never had this procedure done before 
or known from previous authorizations. You also say that the procedure code denied is not the one that was 
used. 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 February 10, 2023 for the 
dental service code represented by D5214. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture - cast metal framework with resin denture bases (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lingual frenectomy (D7962) and collection and 
application of autologous blood concentrate product (D7921). 
 
You asked the Plan to pre-approve lingual frenectomy and collection and application of autologous blood 
concentrate product. You say that this should be covered. The Plan denied your request. The Plan says these are 
not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
lingual frenectomy (D7962) and collection and application of autologous blood concentrate product (D7921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or receiver, 
supplies and accessories. 
 
You asked the Plan to pre-approve the CGM or receiver, supplies and accessories. You say that the enrollee is 
undergoing chemotherapy, is allergic to injected insulin, has recurrent hypoglycemia, and lives alone. 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 CGM or receiver and supplies. have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) or receiver, supplies and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on October 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152-59 (1 Unit) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found CPT code 99152 is not supported, based on Medicare rules. Medicare requires G0500 to be reported for moderate sedation for a gastrointestinal 
endoscopic procedure, not 99152. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If you do have chronic CO2 retention, you may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure (41899). 
 
You asked the Plan to pre-approve the dental services. You say that there are no good dentists in-network. You 
also say that you do not wish to change your dentist of over 20 years and want this to be covered as in-network, 
as the out-of-network out-of-pocket is too high. The Plan denied your request. The Plan says dental services 
from an out-of-network provider 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. 
 
 
 
 You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a dental 
surgery procedure (41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a trip that is 167 
miles. You say this is a very important appointment. The Plan denied your request. The Plan says the benefit 
limit has been exceeded.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 75 miles per one way trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve the additional mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of implant; deep (eg, buried wire, pin, screw, metal 
band, nail, rod or plate) rendered on July 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
pain due to internal orthopedic prosthetic devices, implants, and grafts. He underwent a removal of the 
hardware left shoulder on 7/22/22. However, the provided report states the specimens removed are noted as 
none. Therefore, the records do not support that CPT 20680 was rendered in this case.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) rendered 
on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056) x2 and implant 
supported porcelain/ceramic crown (D6065) x4. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services approved 
because you are having a lot of issues. The Plan denied your request. The Plan says these services are not 
covered under your 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. Prefabricated abutment 
(D6056) and implant supported porcelain/ceramic crown (D6065) are not covered under the Plans dental 
benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6056 and D6065 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutment (D6056) x2 and implant supported porcelain/ceramic crown (D6065) x4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not fit properly; therefore, 
you need new ones. 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. This benefit includes the 
requested complete denture - maxillary (D5110) but is limited to one per 60 floating months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D5110 on December 30, 2019; therefore, your benefit is exhausted. Therefore, we 
decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are unable to do finger pricks, so a CGM is 
medically necessary. The Plan denied your request. The Plan says the Medicare criteria was not 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).