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

 
We decided that the Plan does not have to pre-approve a portable oxygen tank. 
 
You asked the Plan to pre-approve a portable oxygen tank. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen tank have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a portable oxygen tank.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial (63655, 63685). 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
conditions have been 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 a spinal cord stimulator trial. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets all of 
the coverage criteria. A spinal cord stimulator trial is medically reasonable and necessary. 
 
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 spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial (63655, 63685).  
 
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 pay for a comprehensive periodontal evaluation and cone beam 
computed tomography (CT) scan (D0180, D0364) provided on April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 April 16, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation and cone 
beam computed tomography (CT) scan (D0180, D0364) provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4197, B4220, B4224) provided on 
February 24, 2023 to March 1, 2023. 
 
You asked the Plan to pay for the nutritional supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order for the supplies provided in this case. 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 nutritional supplies (B4197, B4220, B4224) provided on 
February 24, 2023 to March 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. 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. 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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SI joint RFA is experimental for back pain. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on May 14, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R73.9 has an Excludes1 note in relation to E11.65. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99233 provided on May 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
cone beam is 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam (D0367).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. 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. 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 genicular radiofrequency ablation. 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 experimental/investigational therapy. It is the subject of 
ongoing clinical trials. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freedom peripheral nerve stimulator (PNS) system 
(64555). 
 
You asked the Plan to pre-approve a Freedom PNS system. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless certain 
conditions have been 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 a Freedom PNS system. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no documentation of a 
multi-disciplinary approach and no psychological evaluation.  Therefore, the request is deemed not medically 
reasonable and necessary. 
 
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 Freedom PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freedom peripheral nerve stimulator (PNS) system (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve debridement of a peri-implant defect or defects 
surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and 
closure (D6101) for teeth numbers 13 and 14. 
 
You asked the Plan to pre-approve debridement of a peri-implant defect or defects surrounding a single 
implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (D6101) for 
teeth numbers 13 and 14. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says This service is not covered in your dental benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the 
exposed implant surfaces, including flap entry and closure (D6101) for teeth numbers 13 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #20 
provided on June 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that the treatment was approved prior to the date of 
service and the service was medically necessary. The Plan denied your request. The Plan says the enrollees 
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 paid for a crown (D2740) and core buildup (D2950) for tooth #18 on June 19, 2023; therefore, 
the enrollees benefit for the requested items or services was exhausted on the date of service of June 19, 2023. 
Therefore, we decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for 
tooth #20 provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on  
June 16, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retreatment of previous root canal therapy (D3346). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 the 
retreatment of previous root canal therapy (D3346).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 24, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you were referred to the surgeon to have 
your tooth removed. The Plan denied your request. The Plan says your benefit for the limited oral evaluation 
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 May 11, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on 
May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for your 
appointments. The Plan denied your request. The Plan says you have exhausted the number of trips covered by 
this plan.  
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 12 
additional trips 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 12 additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595, E0731) provided on 
April 11, 2023. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed items. 
 
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 for the supplies provided in this case. There was not an 
itemized patient receipt for these items. 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 
electrical stimulator supplies (A4595, E0731) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the fixed partial denture sectioning. The Plan denied your request. The Plan 
says dental code D9120 is not listed as a covered dental service. The Plan also says that excluded are services 
related to emergency dental treatment; certain prosthodontic procedures such as bridges and dental implants 
and the surgical preparation for these types of procedures and/or their repair; orthodontics; and services related 
to the treatment of chronic TMJ. 
 
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 
fixed partial denture sectioning (D9120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy (19303). 
 
You asked the Plan to pre-approve a mastectomy. 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. 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 a mastectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided medical records and review of the current peer-reviewed medical literature do not 
support that the bilateral mastectomy for breast pain related to "large, overinflated implants" meets all 
Medicare criteria for medically reasonable and necessary 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 a mastectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a mastectomy (19303).
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 the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the service denied correctly as you do not meet the clinical 
requirements to be approved. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  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 pre-approve the excision of benign lesion (D7412). 
 
You asked the Plan to pre-approve the dental services. You say that you need a new set of dentures, and you 
are in a lot of pain without them. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the excision of benign lesion is 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
excision of benign lesion (D7412).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T11 and L3 (22513, 22514). 
 You asked the Plan to pre-approve kyphoplasty at T11 and L3. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is 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 kyphoplasty at T11 and L3. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no trial of a 
back brace for fracture treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty at T11 and L3 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve kyphoplasty at T11 and L3 (22513, 22514).