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

 
We decided that the Plan does not have to pre-approve a compression burn garment (A6512). 
 
You asked the Plan to pre-approve the compression garment. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested item.  
  
 
 
The Plan must follow Medicare rules. Medicare rules say that compression burn garments are covered when 
they are used to reduce hypertrophic scarring and joint contractures following a burn injury. 
 
The record shows that you do not meet Medicare criteria for coverage of the requested item. Specifically, the 
documentation provided does not show that you have requested this garment due to the presence of a burn. This 
means that you do not have a medical condition for which this compression garment can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve a compression burn garment 
(A6512).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service March 31, 
2023.  
 
You asked the Plan to pay for procedure code 88291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88291 is 1. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88291 
billed for date of service March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic pulpotomy (D3220), the endodontic 
therapy (D3310 and D3320) for tooth #4 and #11 to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the out-of-network provider 
to treat you. The Plan denied your request. The Plan says dental services from an out-of-network provider are 
not covered by your supplemental benefits. Also, there are multiple in-network providers available in your 
service area. 
 
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 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 pre-approve the 
therapeutic pulpotomy (D3220), the endodontic therapy (D3310 and D3320) for tooth #4 and #11 to be 
provided by an out-of-network provider.
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 CGM is medically necessary for the enrollee. 
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 additional documentation from the enrollees 
physician 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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tablets. 
 
You asked the Plan to pre-approve the medication. You say that you were prescribed this medication on May 
25, 2023, upon my release form the hospital where you were being treated for deep vein thrombosis. You also 
say that the original prescription had been prescribed by a hospital doctor on orders from your pulmonary 
critical care doctor, but you were informed that now you need your primary doctor to approve the refill. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed tomographic angiography, pelvis, with contrast 
material(s) (72191). 
 
You asked the Plan to pre-approve a Computed tomographic angiography. The Plan denied your request. The 
Plan says that the requested services is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a Computed tomographic angiography. 
Our reviewer says that you need this medical item. Our physician reviewer found the requested CTA of the 
pelvis is requested to provide a roadmap for intended prostate artery embolization to treat BPH.  If the 
embolization procedure is approved the request is reasonable to plan an embolization approach.  The 
embolization procedure has gained support in the urology literature. 
 
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 Computed tomographic angiography have been met. Therefore, we decided 
that the Plan has to pre-approve a Computed tomographic angiography, pelvis, with contrast material(s) 
(72191).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enrollee needs this MRI, as attached in the records 
herein. 
 
You asked the Plan to pre-approve the medical records do not show the enrollee had a face-to-face visit with 
physician in the last 60 days and the medical records do not show the enrollee was seen 3 months after 
completing a 6-week trial of non-surgical (conservative) treatment.. You say that the enrollee needs this MRI, 
as attached in the records herein. The Plan denied your request. The Plan says the medical records do not show 
the enrollee had a face-to-face visit with physician in the last 60 days and the medical records do not show the 
enrollee was seen 3 months after completing a 6-week trial of non-surgical (conservative) treatment.  
 
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 medical records do not show the 
enrollee had a face-to-face visit with physician in the last 60 days and the medical records do not show the 
enrollee was seen 3 months after completing a 6-week trial of non-surgical (conservative) treatment.. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the neuro exam was 
normal, no conservative therapy including physical therapy has been given, no red flag, and no contraindication 
to 6 weeks of supervised PT to prove medical necessity.  
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 medical records do not show the enrollee had a face-to-face visit with 
physician in the last 60 days and the medical records do not show the enrollee was seen 3 months after 
completing a 6-week trial of non-surgical (conservative) treatment. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the enrollee needs this MRI, as attached in the records herein.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74230, 72040, 70100, 70310, and 74240 
provided on January 27, 2023. 
 
You asked the Plan to pay for procedure codes 74230, 72040, 70100, 70310, and 74240. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services have not been met. The documentation supports that the enrollee was at a 
skilled nursing facility on the date of service. As such, the use of the inpatient hospital POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for procedure codes 74230, 72040, 
70100, 70310, and 74240 provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the limited oral evaluation-problem 
focused (D0140), pulp vitality tests (D0460), and the cone beam computed tomography (CT) image capture 
with limited field of view (D0380) provided on January 25, 2023.  
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 20% 
coinsurance for Non-Medicare covered preventive and comprehensive dental services rendered by an out-of-
network provider.  
  
 
 
You have been asked to pay $104.80 ($28 + $12 + $64.80) for the Non-Medicare covered dental services 
rendered by an out-of-network provider. 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. This includes the Plans allowed amount of $112 x 20% coinsurance=$28 for the limited 
oral evaluation, the Plans allowed amount of $60 x 20% coinsurance=$12 for the pulp vitality test, and the 
Plans allowed amount of $324 x 20% coinsurance=$64.80 for the cone beam CT image capture provided. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the limited oral evaluation-
problem focused (D0140), pulp vitality tests (D0460), and the cone beam computed tomography (CT) image 
capture with limited field of view (D0380) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6084 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and cannot eat. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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 
implant supported crowns (D6084 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core (D2954) for tooth #2 and 
#4 and the local anesthesia (D9215). You asked the Plan to pre-approve the dental services. You say that the dental procedures are covered under 
your emergent procedures and the Plan should cover them. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the prefabricated post and core is not covered by 
the Plan and the local anesthesia is considered an integral part of the entire dental service that has already been 
approved. 
 
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 
prefabricated post and core (D2954) for tooth #2 and #4 and the local anesthesia (D9215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty (D7320) and the removal of lateral 
exostosis (D7471). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the alveoloplasty and the removal of lateral exostosis 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. 
 
  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 
alveoloplasty (D7320) and the removal of lateral exostosis (D7471).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee needs to begin a more aggressive 
therapy to obtain symptom relief and Dupixent is the best choice to ensure that their life is no longer negatively 
affected by their unfortunate condition. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. The Plan denied your request. The Plan 
says your benefit for the complete denture - maxillary  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 complete maxillary denture was exhausted on date of service January 18, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) provided on January 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were sent to a specialist and the evaluation 
was necessary for your tooth ache. The Plan denied your request. The Plan says that your benefit for the 
requested item or service has already been exhausted because you received on less than 3 months from the date 
of service. 
 
The rules say the benefits offered under a plan, including applicable conditions and limitations, premiums and 
cost-sharing, and any other conditions associated with receipt or use of benefits. Your contract with the Plan 
does not say in clear and accurate terms that the benefit for the limited oral evaluation (D0140) is limited to 1 
every 3 months.  
 
We looked at your contract with the Plan. We did not see where the contract says that limited oral evaluations 
(D0140) is limited to 1 every 3 months. The contracts says that a limited oral evaluation (D0140) is covered for 
3 a year, and there is no evidence that the benefit as it is stated has been exhausted. This means that the Plan 
did not follow Medicare rules for disclosure of the applicable conditions and limitations, premiums and cost-
sharing, and any other conditions for the limited oral evaluation (D0140). Therefore, we decided that the Plan 
has to pay for a limited oral evaluation (D0140) provided on January 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
each additional radiographic image (D0230), endodontic therapy, premolar tooth (excluding final restoration) 
(D3320), and intraorifice barrier (D3911) provided on February 14, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0220, D0230, D3320 and D3911. You 
say that the dental procedures were related to a fall on October 17, 2022. The Plan denied your request. The 
Plan says your benefit for the requested services $775 dollar limit was met 
 
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 services was exhausted on dates of service January 25, 2023, and February 
2, 2023. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic 
image (D0220), each additional radiographic image (D0230), endodontic therapy, premolar tooth (excluding 
final restoration) (D3320), and intraorifice barrier (D3911) provided on February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ezetimibe. 
 
You asked the Plan to pre-approve the medication. You say that you hope the submitted records help the Plan 
recognize the medical necessity and importance of continuing ezetimibe as part of the members treatment. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ezetimibe.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye examination (92002) provided on April 04, 
2023. 
 
You asked the Plan to pay for a new patient eye examination (92002). You say that an authorization should be 
on file for the members stay at this facility. 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 new patient eye 
examination (92002) provided on April 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), comprehensive oral 
evaluation (D0150), and the intraoral-complete series of radiographic images (D0210) provided on  
February 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental cleaning (D1110), comprehensive 
oral evaluation (D0150), and the intraoral-complete series of radiographic images (D0210) provided on 
February 14, 2023.