Persius/hicric huggingface dataset:
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 a CGM. You say that the enrollee is blind and needs to hear his readings. 
The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug. The enrollee 
has not tried and failed the required drugs. The available documentation does not support that Orthovisc or 
Supartz FX would likely be less effective and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis (J7322). 
 
You asked the Plan to pre-approve Hymovis. You say that Hymovis is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc OR Supartz FX is required before alternatives can be 
considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Hymovis. Our reviewer says that 
Hymovis is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis (J7322).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental cleaning (D1110). 
 
You asked the Plan to pre-approve this dental service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service October 31, 2022. Specifically, 
the Plan contract states that dental cleanings are covered twice every twelve months. You previously received 
this service on April 12, 2022 and October 31, 2022, less than twelve months prior, which were paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this service at this time. Therefore, we decided 
that the Plan does not have to pre-approve a dental cleaning (D1110).
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 July 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. 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 July 30, 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 July 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestlye Libre 3. 
 
You asked the Plan to pre-approve a Freestlye Libre 3. You say that you would like the Plan to approve a 
Freestlye Libre 3. The Plan denied your request. The Plan says the requested item is not covered by Medicare. 
 
We looked at the file and Medicare rules. The requested Freestyle Libre 3 is not specified as a product that may 
be classified using code E2103. Therefore, this device is not covered by Medicare at this time. Based on this 
information, we decided that Medicare rules for coverage of a Freestlye Libre 3 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestlye Libre 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periapical radiographic 
image (D0220), bitewings (D0274), panoramic radiographic image (D0330), and extractions (D7140 and 
D7210) for tooth #2 and #3 provided by an out-of-network provider on May 5, 2022, and May 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the in-network provider was no longer at the 
office, and you saw the new dentist. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. Also, it was 
verified that you were given an in-network provider and there was no inquiry about the 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. 
 The record shows you received the requested 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 pay for a periodic oral evaluation (D0120), periapical radiographic image (D0220), bitewings (D0274), 
panoramic radiographic image (D0330), and extractions (D7140 and D7210) for tooth #2 and #3 provided by 
an out-of-network provider on May 5, 2022, and May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that the services are medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the member meets criteria. The Plan made several 
attempts for medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. No medical 
records were provided. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental 
Benefits for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for a consult for medical nutrition 
therapy. 
 
You asked the Plan to pre-approve an office visit for a consult for medical nutrition therapy services. You say 
that the service is medically necessary. The Plan denied your request. The Plan says the member does not have 
diabetes or renal disease. 
 
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.  
 
The records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan 
does not have to pre-approve an office visit for a consult for medical nutrition therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that you would like coverage of replacing 
the enrollee's wheelchair seat/cushion to be reconsidered. The Plan denied your request. The Plan says since 
total repair cost is higher than replacement costs, the denial is upheld. The Plan also says that the total repair 
cost (including cost of previous repairs) is $5,835.38, which exceeds more than the cost of the assistive device 
as currently configured ($3,042.71). 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
 
 
 We looked at the file and Medicare rules. Specifically, the Plan does not have to cover repairs when the sum 
total cost of repairs exceeds the cost of replacing the item. Based on this information, we decided that Medicare 
rules for coverage of the wheelchair repairs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair repairs.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visits provided on April 14, 2022, and 
May 7, 2022. 
 
You asked the Plan to pay for the emergency department visits. You say that you were not in hospice on these 
dates of service. The Plan denied your request. The Plan says the member was enrolled in hospice at the time 
services were rendered. The claims should be submitted to Original Medicare for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for emergency department visits provided on April 14, 2022, and 
May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), the extraction, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graft for ridge 
preservation (D7953), guided tissue regeneration (D4266), osseous surgery-one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261 x 4), occlusal adjustments (D9951 x 2), non-intravenous conscious 
sedation (D9248), cone beam computed tomography (CT) image capture with field of view of both jaws; with 
or without cranium (D0383), and surgical placement of an implant body; endosteal implant (D6010) to be 
rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services from an unassigned, 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 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 periodontal 
maintenance (D4910), the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210), bone replacement graft for ridge preservation (D7953), guided tissue regeneration (D4266), osseous 
surgery-one to three contiguous teeth or tooth bounded spaces per quadrant (D4261 x 4), occlusal adjustments 
(D9951 x 2), non-intravenous conscious sedation (D9248), cone beam computed tomography (CT) image 
capture with field of view of both jaws; with or without cranium (D0383), and surgical placement of an implant 
body; endosteal implant (D6010) to be rendered by the out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on August 30, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the claim was sent on September 6, 2020 
which is within the 90 days of the date of service. The Plan denied your request. The Plan says the claim was 
not received within the 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance service was not filed until October 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance service provided on August 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on September 30, 2022. 
 
You asked the Plan to pay for diabetic supplies. You say that the enrollee needs these diabetic supplies. The 
Plan denied your request. The Plan says these supplies have been correctly denied. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The date of delivery was prior to the date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for diabetic supplies provided on September 30, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you the additional amount for the COVID-19 at-home test kits 
provided on July 11, 2022, and July 22, 2022. 
 
You asked the Plan to reimburse you an additional amount for COVID-19 at-home test kits. You say that you 
should be reimbursed the full amount. The Plan denied your request. The Plan says that the member must 
accept Medicare rates for the COVID test. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022 and continues until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 at-home test kits have been met. Therefore, we decided that the Plan has to reimburse 
you the additional amount for COVID-19 at-home test kits provided on July 11, 2022, and July 22, 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: 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. The Plan denied your request. The Plan says you do not require 
insulin three or more times daily. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that the 
CGM is not medically necessary. Our physician reviewer found we were not told that you are taking 3 shots a 
day or that you adjust the doses based on blood glucose levels. The reviewer also says that 70/30 is usually 
given two times a day and is only used on a sliding scale.  With the data provided, criteria for coverage has not been met. If additional data is provided, it should be 
submitted and the case re-reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing - single radiographic image (D0270) and crown - 
porcelain/ceramic (D2740) provided on October 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to have the requested services, so you 
hope your insurance will cover them. 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 bitewing - single radiographic image (D0270) but is limited to one procedure per calendar year. 
Crown - porcelain/ceramic (D2740) is not covered under the Plans dental benefits. 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown - 
porcelain/ceramic (D2740) provided on October 3, 2022. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered bitewing  four 
radiographic images (D0274) on July 18, 2022, and received covered bitewing - single radiographic image 
(D0270) on October 3, 2022. Therefore, this benefit was exhausted as of July 18, 2022. Although these are two 
different services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, we decided that the Plan does not have to pay for bitewing - single 
radiographic image (D0270) on October 3, 2022.
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 due to decreased vision the patient 
cannot see where he is sticking himself. You also say that he is unable to see where to put the sample on the 
strip. 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 pre-approve an upper partial denture (D5225) and a lower partial 
denture (D5226). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items has been exhausted on date of service August 10, 2022. Specifically, 
the Plan contract provides coverage for dentures once every five years. You previously received these items on 
August 10, 2022, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for 
these items at this time. Therefore, we decided that the Plan does not have to pre-approve an upper partial 
denture (D5225) and a lower partial denture (D5226).