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

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs a new partial denture. 
The Plan denied your request. The Plan says the enrollee's 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 the enrollee's benefit for the requested item or service was exhausted on date of service May 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the phlebotomy services provided on May 
08, 2023. 
 
You asked the Plan to waive the copayment for the phlebotomy services. You say that this did not occur at the 
location shown on your explanation of benefits. 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 $50 
copayment for outpatient surgery. 
 
You have been asked to pay a $50 copayment for the phlebotomy services. This item/service falls within the 
outpatient surgery 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. The record shows this claim was approved and you are responsible for the cost share amount. 
However, since the allowed amount is less than the standard copayment, you only owe $47.55. Therefore, we 
decided that the Plan does not have to waive the copayment for the phlebotomy services provided on May 08, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that you are currently in the hospital and 
are needing the ventilator for oxygen and to help you sleep during the night.  The Plan denied your request. The 
Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that you were 
recently hospitalized with pneumonia, congestive heart failure and exacerbation of COPD. Although you had 
been previously admitted requiring intubation, there are no pulmonary function tests to assess the severity of 
the COPD. Also, there was no arterial blood gas analysis (ABG) done while stable to document chronic carbon 
dioxide retention. If that is present, then you may benefit from BiPAP with AVAPS during sleep as an 
outpatient. Therefore, a home ventilator is not medically 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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutritional therapy 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the service should be 
covered. The Plan denied your request. The Plan says you do not  suffer from renal disease or diabetes. 
 
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.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutritional therapy
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins (37765). 
 
You asked the Plan to pre-approve stab phlebectomy of varicose veins. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria of medical necessity. 
 
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 stab phlebectomy of varicose veins. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not satisfactorily demonstrate that the varicose 
vein is causing a significant problem. The duplex examination suggests severe reflux in the left great saphenous 
vein. It is not clear, however, how extensive the reflux is throughout the left great saphenous vein. Phlebectomy 
without addressing associated severe reflux has a high rate of recurrence justifying the denial of isolated 
phlebectomy. Perhaps most importantly however, is that the enrollees symptoms cannot be attributed to the 
varicose veins without an assessment of lower extremity arterial perfusion. The reasonableness and medical 
necessity of any venous procedures without assessment of lower extremity arterial perfusion cannot be 
supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy of varicose veins have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stab phlebectomy of varicose veins (37765).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because based on the medical literature 
this procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollee's condition. 
 
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 artery embolization. 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. 
 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 artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36246, 36247).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve polysomnography (95810). 
 
You asked the Plan to pre-approve polysomnography. 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 sleep studies are 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 polysomnography. Our reviewer says 
that the services are medically necessary. Our physician reviewer found based on the medical records provided 
there is documentation of significant concern for sleep apnea in the enrollee. There is no requirement in the 
Medicare rules that this enrollee have a home sleep test as opposed to a sleep study in a sleep lab.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve polysomnography (95810).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 24, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were unaware 
of 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the 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 the 
ambulance transportation provided on July 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you need the item. The Plan denied your 
request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin or 
have a documented history of low blood sugar (hypoglycemia). Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure should be covered because 
your previous provider did bad work. 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 September 14, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), unspecified 
fixed prosthodontic procedure, by report (D6999), and extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that these services are a medical necessity. The 
Plan denied your request. The Plan says the requested surgical extractions and dental implants are not a 
covered benefit under your benefit 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210), unspecified fixed prosthodontic procedure, by report (D6999), and 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140).
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 the medical records provided 
support the need for the requested FreeStyle Libre 3 sensor. The Plan denied your request. The Plan says the 
enrollee does not meet criteria per the medical necessity guidelines. 
 
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 or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241), and two retainer crowns (D6751). 
 
You asked the Plan to pre-approve D6241 and D6751. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6241), and two retainer crowns (D6751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you obtained a physician's order 
and selected an in-network provider per the plan's customer service representative. You also say that per your 
medical history you respectfully request a reconsideration for this claim and approve the compression stockings 
as medically necessary. The Plan denied your request. The Plan says the product is not covered under your 
plan.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5120/D5110). 
 
You asked the Plan to pre-approve dentures. You say that you would like the Plan to approve and pay for 
dentures. The Plan denied your request. The Plan says dentures are not covered 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 
dentures (D5120/D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment  includes placement 
(D6057), abutment supported porcelain fused to metal crown (high noble metal) (D6059), surgical placement 
of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says dental implants and associated services are not covered by Medicare or 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
custom fabricated abutment  includes placement (D6057), abutment supported porcelain fused to metal crown 
(high noble metal) (D6059), surgical placement of implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950), and a re-cemented crown (D2920) 
provided on July 17, 2023. 
 
You asked the Plan to pay for D2950 and D2920. You say that crowns are covered. The Plan denied your 
request. The Plan says the denied dental services are not covered 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 pay for a core 
build-up (D2950), and a re-cemented crown (D2920) provided on July 17, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on December 27, 2021. 
 You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible 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.  
 
The enrollee was 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 the physician services provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the orthotics are medically necessary for the enrollee. 
The Plan denied your request. The Plan says this item is not a covered benefit. The Plan says that the enrollee 
does not have diabetes. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
tried conservative therapy.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our physician reviewer 
found that a review of the current medical literature indicates that this service or item is considered to be 
reasonable and necessary after a trial and failure or contraindication of at least 3 months of conservative 
therapy; and failure of or contraindication to intra-articular glucocorticoid injections. In this case, the records 
do not include evidence of conservative non-pharmacologic therapy and simple analgesics that have been tried 
for at least three months. The documentation does not support that Durolane is indicated for the enrollee's 
condition. The documentation does not support that Durolane is medically reasonable or 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.