Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 and supplies. 
 
You asked the Plan to pre-approve the Dexcom G6 and supplies. You say that you are appealing because the 
enrollee has type 2 diabetes mellitus without complications. The Plan denied your request. The Plan says the 
clinical information provided does not show the enrollee has meet criteria for a continuous glucose monitor 
system and standard supply allowance for this device. 
 
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 Dexcom G6 and supplies. Our 
reviewer says that the Dexcom G6 and supplies are not medically necessary. Our physician reviewer found the 
patient must be using insulin or having low blood glucose sugar to qualify for the CGM. There is a lack of 
documentation showing that this is the 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 the Dexcom G6 and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 and supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 provided on May 7, 2022. 
 
You asked the Plan to pay for procedure code 99283. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99283 is included in the global surgery 
payment for procedure code 29125 provided on May 7, 2022. Separate payment cannot be made for procedure 
code 99283. Based on this information, we decided that Medicare rules for coverage of procedure code 99283 
have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 99283 
provided on May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you need your chair for 
getting around and doing your daily activities. You say that your legs shake really bad and sometimes cannot 
move four feet before losing legs and having weakness. You also say that your wheelchair is irreparable 
damaged. The Plan denied your request. The Plan says there was no evidence provided that your current power 
wheelchair has been lost or irreparably damaged. The Plan also says that your current power wheelchair is less 
than five years old. 
 The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement Group 2 power wheelchair (K0823).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergency transportation. You say that you can not go to the gym 
because there are no trips left. The Plan denied your request. The Plan says you may contact CarePlus Member 
Services department at 1-800-794-5907 TTY: 711 to explore which plan is best suited for your needs. 
 
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 
non-emergency transportation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment for tooth #29, #30 (D6057) 
and abutment supported porcelain/ceramic crown (D6058). 
 
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 you have already been approved for 2 implants anything over this is not covered. 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutment for tooth #29, #30 (D6057) and abutment supported 
porcelain/ceramic crown (D6058).
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 benefits. You say that the enrollee depends on this resource that she 
had had in years past. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS3D testing (88361, 88312, 88305, 88112) 
provided on August 23, 2022.  
 
You asked the Plan to pay for the WATS3D testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says the clinical value and effectiveness of WATS3D testing for screening, 
diagnosis, or surveillance of cancerous or pre-cancerous esophageal lesions have not been demonstrated in the 
peer-reviewed literature.  
 
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 pay for the WATS3D testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the available record does not support the high likelihood of Barretts esophagus, and thus 
does not meet the spirit of American Society for Gastrointestinal Endoscopy (ASGE) guidance relative to 
medically necessary use of WATS-3D in this case. The submitted ICD-10 code indication for WATS makes 
clear that the enrollees gastroesophageal reflux disease (GERD) is seen by the provider as uncomplicated. 
 
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 WATS3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS3D testing (88361, 88312, 88305, 88112) provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket dressing (D7922) and primary 
closure of a sinus perforation (D7261). 
 
You asked the Plan to pre-approve placement of intra-socket dressing and primary closure of a sinus 
perforation. You say that this should be covered. The Plan denied your request. The Plan says this is not a 
covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
placement of intra-socket dressing (D7922) and primary closure of a sinus perforation (D7261).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OralCDx Brush Test (88361, 88104, 88312, 88305) 
provided on March 29, 2022.  
 
You asked the Plan to pre-approve the OralCDx Brush Test . You say that this testing is recommended in the 
standard of practice guideline of major medical studies. The Plan denied your request. The Plan says the 
clinical value and effectiveness of OralCDx Brush Testing for screening, diagnosis, or surveillance of 
cancerous or pre-cancerous oral lesion have not been demonstrated in the peer-reviewed literature.  
 
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 OralCDx Brush Test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available records do not support that the sampled area of the enrollee's tongue 
raised high suspicion of dysplasia, nor that the enrollee is a high risk for oral cancer. Appropriate sampling of 
suspicious lesions is biopsy and traditional histologic analysis. The medical necessity and appropriateness of 
OralCDx testing in this case is not supported by the available records. 
 
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 OralCDx Brush Test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the OralCDx Brush Test (88361, 88104, 88312, 88305) provided on March 29, 
2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services. 
 
You asked the Plan to pay for the ER services. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the provider is not enrolled in Medicare. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not submitted sufficient evidence that the physician is not enrolled 
in Medicare. Therefore, we decided that the Plan has to pay for the emergency room (ER) services.  
 
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 implant placement (D6010), implant supported 
porcelain fused to metal crown (D6066) and bone replacement graft (D7953). 
 
You asked the Plan to pre-approve implants and associated services. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
implant placement (D6010), implant supported porcelain fused to metal crown (D6066) and bone replacement 
graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the Freestyle Libre 3. You say that you would like the Plan to approve the 
Freestyle Libre 3. The Plan denied your request. The Plan says the requested CGM is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time.  Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the genicular nerve block billed for date of service January 20, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the charges. The 
Plan denied your request. The Plan says that the diagnosis codes do not fall under the coding requirements.  
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A57452, the Plan used in their decision to 
deny services does not show that only the diagnoses listed are covered. There are no diagnosis codes that are 
listed as not meeting medical necessity. The Plan has offered no other rationale for their denial. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the genicular nerve block billed for date 
of service January 20, 2023.  
 
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 Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that you are appealing the 
denied Dexcom G7 sensor. The Plan denied your request. The Plan says only the preferred brand products 
listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the continuous glucose monitor (CGM). Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that it will be easier to use the 
FreeStyle Libre 3 sensor and you do not want to go back to the stone age with an older option. The Plan denied 
your request. The Plan says you are requesting a CGM product that does not meet Medicare's definition of 
durable medical equipment (DME) and, therefore, is not in a defined Medicare benefit category. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time.  Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test determines which medications may 
require dose adjustments.  The Plan denied your request. The Plan says without medical records, medical 
necessity cannot be determined.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to 
make decisions about the enrollees medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on an enrollees response to the medication. In this case, medical 
records from the treating physician were not provided. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing billed for date of service January 23, 2023.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the SNF stay. We decided that the Plan does not 
have to waive the deductible and coinsurance for the SNF stay.  
 You asked the Plan to waive the deductible and coinsurance for the SNF stay from November 15, 2022, to 
November 18, 2022. You say that you were not charged for a previous stay at the SNF. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the SNF stay.  
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says enrollees must pay 40% coinsurance per stay for each out-of-network SNF stay. The Plans 
allowed amount for the SNF stay was $10,952.86. The Plan applied a $609.31 deductible which met your $750 
deductible for the year. After the deductible was applied, the remaining allowed amount of the claim is 
$10,343.55. Therefore, your coinsurance responsibility is $4,137.42. 
 
The Plan has asked you to pay $4,187.67, which is more than 40% coinsurance for an out-of-network SNF 
stay. Based on your contract with the Plan, however, you cannot be asked to pay more than $4,137.42, which is 
40% coinsurance for this SNF stay. Therefore, we decided that the Plan has to reduce your coinsurance amount 
for this claim from $4,187.67 to $4,137.42. 
 
We also decided that the Plan does not have to waive the deductible and coinsurance for the SNF stay. 
 
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 $750 
deductible and 40% coinsurance per stay for each out-of-network SNF stay. At the time this claim was 
processed, $140.69 of the $750 deductible had been met. The allowed amount of this claim is $10,952.86, 
resulting in a deductible amount of $609.31 because this met the $750 deductible for the year. After the 
deductible was applied, the remaining allowed amount of the claim is $10,343.55, resulting in a coinsurance 
amount of $4,137.42. Therefore, your total cost-sharing amount is $4,746.73. Therefore, we decided that the 
Plan does not have to waive the deductible and coinsurance for the SNF stay. 
 
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.