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

 
We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement 
(D6057), abutment supported porcelain/ceramic crown (D6058), and a bone craft (D0351). 
 
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 your benefit for the abutment 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 abutment was exhausted. A bone craft is not a covered service. Therefore, we 
decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), and a bone craft (D0351).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE testing. You say that the enrollee should undergo an updated TTE 
given abnormal electrocardiogram, history of hypertension, and history of abnormal heart rhythm. The Plan 
denied your request. The Plan says the enrollee has no heart related complaints. 
 
The Plan follows Medicare rules. Medicare rules state that TTE testing may be covered for certain applications. 
 
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 TTE testing. Our reviewer says that the 
enrollee does not meet criteria for this testing. Our physician reviewer found at issue is the medical necessity of 
repeat TTE in the absence of any apparent significant change int eh enrollee's clinical condition. Clinical 
guidelines do not support a TTE with no intervening change in clinical status or physical findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
received on July 9, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport. You say that the 
services were medically necessary due to your allergic reaction. The Plan denied your request. The Plan says 
ambulance treatment without transport is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 9, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport received on July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on August 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you thought it would be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for a one-way trip. 
 
You asked the Plan to pre-approve additional miles for a one-way trip. You say that you have a trip to your 
pain management doctor. The Plan denied your request. The Plan says your request exceeds the benefit limit 
for the transportation program. 
 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 60 miles for each one way  trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 additional miles for a one-way trip.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee would benefit from 
these compression stockings. The Plan denied your request. The Plan says the requested compression stockings 
have been correctly denied. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
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 it is difficult to do your testing at work so you need 
a CGM to use while working. The Plan denied your request. The Plan says the Medicare criteria was 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. Specifically, the prior authorization form from your physician 
indicates that you do not use insulin or have a history of problematic hypoglycemia 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis for a Group 3 power 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not 
available at the acute care hospital where they are currently receiving care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. The enrollee is 
improving and does not require LTACH services as they do not meet criteria. At this time, the enrollee's needs 
can be met at the current level of service.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code 99053. You say that the attached medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says procedure code 
99053 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
  We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical shoulder arthroscopy (29826, 29828) provided to
the enrollee on January 26, 2023.

You asked the Plan to pay for the surgical shoulder arthroscopy. You say that this should be paid for. The Plan
denied your request. The Plan says that the denied codes are not supported by the medical records submitted.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for surgical shoulder
arthroscopy (29826, 29828). Our Medical Director states that arthroscopic biceps tenodesis entails surgery to
repair and reattach a damaged biceps tendon. The clinical documentation does not support that biceps tenodesis
(29828) was performed in this case. The decision was made intraoperatively to not perform the subacromial
decompression due to the rotator cuff tear and the amount of arthritis. Therefore, the records do not support that
CPT 29826 was rendered in this case. Our Medical Director found that the records do not support procedure
codes 29826 and 29828.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgical shoulder arthroscopy have not been met. Therefore, we decided that
the Plan does not have to pay for the surgical shoulder arthroscopy (29826, 29828) provided to the enrollee on
January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device (22869, 22870). 
 
You asked the Plan to pre-approve an interspinous stabilization device. You say that you disagree with the 
denial. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not 
covered by Medicare. 
 
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 interspinous stabilization device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found interspinous devices are experimental and investigational. There is 
more research needed due to insufficient evidence of efficacy. 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 interspinous stabilization device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device (22869, 22870).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the 
step therapy requirements have not been met. Our physician reviewer found the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT capture and interpretation (D0367). 
 
You asked the Plan to pre-approve cone beam CT capture and interpretation . 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 cone 
beam CT capture and interpretation (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided June 
28, 2023.   
You asked the Plan to pay for the ultraviolet light therapy system. You say that you are requesting 
reconsideration and have attached the supporting documentation. Please reprocess the claim. The Plan denied 
your request. The Plan says under Medicare guidelines, your request 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 looked at the file and Medicare rules. The record does not show a diagnosis of psoriasis. There is also no 
indication that intractable psoriasis, as there is no indication the enrollee has failed other treatments for 
psoriasis. There are also no other factors described that would justify treatment at home rather than alternative 
sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI of the cervical spine. You say that the requested MRI is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because there was no documentation that other treatment was tried, and they failed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI of the cervical spine. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found that the enrollee has 
chronic neck pain related to a prior car accident with x-ray showing moderate spondylosis. An MRI of the 
cervical spine was requested. However, the provided documentation did not clearly describe the enrollee as 
having tried and failed activity modification, exercises/stretches, formal physical therapy, or other conservative 
treatments for their condition prior to considering advanced imaging. Also, physical findings did not reveal 
signs of a red flag diagnosis which might warrant bypassing these first line therapies. 
 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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that there has been improvement to your 
condition with PT.  The Plan denied your request. The Plan says you do not meet the criteria for the continued 
PT request.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have refractory polyneuropathy and are unresponsive to therapy. 
Rationale for continued therapy based on your response to prior therapy is not provided.   
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continued physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided on August 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have only had bitewings taken this year. 
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 January 26, 2022. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided on August 
2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the powered pressure-reducing air mattress (E0277).  
 
You asked the Plan to pay for the powered pressure-reducing air mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the criteria listed 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 pay for the powered pressure-reducing air mattress. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee does not 
have non-healing multiple stage 2 or a large stage 3 or 4 ulcers. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pay for the powered pressure-reducing air mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown, porcelain fused to high noble metal 
(D6750) and a pontic, porcelain fused to high noble metal (D6240). 
 
You asked the Plan to pre-approve these dental 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 
retainer crown, porcelain fused to high noble metal (D6750) and a pontic, porcelain fused to high noble metal 
(D6240).