Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #8 
and #9 to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the service should be covered, and the 
provider should be in-network. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. Also, crowns are not 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 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 core buildup is not covered under this benefit when received from an out-of-
network provider. The crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #8 and #9 to be 
provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has no standing or 
walking tolerance. You say that the enrollee's pain interferes with their activities of daily living including 
functional mobility and self-care task. The Plan denied your request. The Plan says the genicular nerve block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically reasonable and necessary. Our physician reviewer found 
that the genicular nerve block is considered experimental and investigational. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96138). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says psychological testing requires a clinically trained examiner. All 
psychological tests should be 
administered, scored, and interpreted by a trained professional such as a clinical psychologist, psychologist, 
advanced nurse practitioner with education in this area, or a physician assistant who works with a psychiatrist 
with expertise in the appropriate area. Testing conducted when no mental illness/disability is suspected would 
be considered screening and would not be covered. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing can be covered when 
specific criteria are met. 
 
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 neuropsychological testing. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found the case file 
does not contain documentation that the enrollee has deficits on standard mental status testing or clinical 
interview, and that a neuropsychological assessment is needed to establish the presence of abnormalities or 
distinguish them from other disease processes. In addition, there is no documentation that any of the other 
medically necessary indications for this testing established by the LCD are met 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 neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96138).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular dentures (D5110 
and D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the first set of dentures do not fit properly, 
so a new pair is needed. 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 May 31, 2023. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular dentures (D5110 
and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to a crown 
(D2954). 
 
You asked the Plan to pre-approve D2954. You say that you need this post and core after your root canal. The 
Plan denied your request. The Plan says D2954 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated post and core in addition to a crown (D2954).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent of the genicular nerve 
(64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent of the genicular nerve. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 destruction by neurolytic agent of the 
genicular nerve. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational 
procedure. It is the subject of ongoing clinical trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent of the genicular nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent of the 
genicular nerve (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 200 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you have to make frequent trips to the 
doctor due to having liver Cirrhosis to have your abdomen drained weekly or it becomes life threatening. You 
also say that you do not drive ort have anyone that can drive you. The Plan denied your request.  The Plan says you have used all your rides already for the year. Your request for 200 rides in addition to the 36 
one-way rides you are covered for exceeds the benefit limit. 
 
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 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 200 
additional rides for your appointments. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 200 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on electrocardiogram monitoring. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
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 this CGM is medically necessary. The Plan denied 
your request. The Plan says the enrollee is not using insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and X-ray services to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and X-ray services. You say that the services should be 
covered. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and X-ray services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E1002, E1028, E2310, E2361, E2607, 
E2620, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee meets all medical necessity requirements, and has a group 3 diagnosis. The Plan 
denied your request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility 
limitation for which a K0856 group 3 power wheelchair is medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the base power wheelchair is not covered, all related accessories will also be denied. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Our reviewer found 
that although the enrollees condition may meet criteria for a PWC, the criteria for this specifically requested 
PWC with multiple power options including power tilt and recline are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E1002, 
E1028, E2310, E2361, E2607, E2620, and K0040).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on April 14, 2023. 
 
You asked the Plan to pay for physician services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, records show the patient was 
an outpatient, however the claim was billed with an inpatient place of service (21). Based on this information, 
we decided that Medicare rules for coverage of physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99223) provided on April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this is medically necessary. The 
Plan denied your request. The Plan says the documentation does not show syncope or cryptogenic stroke. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on April 05, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit evaluation 
provided on April 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's 
condition does not meet these Medicare criteria. The Plan says that the services needed may be provided safely 
in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 15, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you received poor 
care, and should not have to pay the copayment.. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $220 
copayment for ambulance services. 
 
You have been asked to pay a $220 copayment for an ambulance transportation. This item/service falls within 
the ambulance services 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 an 
ambulance transportation provided on May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
acute rehabilitation stay. The Plan denied your request. The Plan says the enrollee's records do not show to 
have complex rehabilitation needs that require frequent evaluation by a rehabilitation physician or need an 
intensive multidisciplinary team. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on December 9, 2022, 
through December 21, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says this provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) provided on 
December 9, 2022, through December 21, 2022.