Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the parking fees (S9975) from January 6, 2021, 
through July 12, 2021. 
 
You asked the Plan to reimburse you for the parking fees. You say that you would like to be reimbursed for the 
hospital parking fees. The Plan denied your request. The Plan says parking fees are not covered by Medicare, 
and no payment can be issued. 
 
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. Specifically, parking fees would not fall under the definition of 
reasonable transportation to a distant facility. In addition, the Plans contract language specifies that their 
coverage of transplant service-related transportation costs is limited to costs to and from the facilities providing 
transplant related care. Parking fees are not considered reasonable and necessary for the diagnosis or treatment 
of an illness or injury. Based on this information, we decided that Medicare rules for coverage of the parking 
fees have not been met. Therefore, we decided that the Plan does not have to reimburse you for the parking fees 
(S9975) from January 6, 2021, through July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950). We decided that the Plan does not have to pay for occlusal 
adjustment - limited (D9951) provided on August 30, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with the denial of the 
requested services. 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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services dental services and may be billed by the out-of-network 
provider for any charged amount greater than the payment made by the Plan. Occlusal adjustment - limited 
(D9951) is not covered under the Plans dental benefits. 
 
The allowed amounts of the covered dental services total $678, resulting in a coinsurance amount of $339 and 
Plan payment amount of $339. 
 
You may also be 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 crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided on August 30, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, code D9951 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for occlusal adjustment - 
limited (D9951) provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has idiopathic pulmonary fibrosis with a moderate impairment in forced expiratory volume (FEV1) and a restrictive pattern on 
spirometry. There is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive 
disease, or neuromuscular disease. There is no arterial blood gas (ABG) showing carbon dioxide retention. The 
criteria for coverage are not met and the requested ventilator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic images (D0350) provided on 
January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 18, 2023. 
Therefore, we decided that the Plan does not have to pay for oral/facial photographic images (D0350) provided 
on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block procedures (64490, 64491). 
 
You asked the Plan to pre-approve medial branch blocks. You say that medial branch blocks are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medial branch blocks are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve medial branch blocks. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has radicular pain. The enrollee does not meet the criteria for the 
requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch block procedures (64490, 64491).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hepatobiliary system imaging (78227). 
 
You asked the Plan to pre-approve hepatobiliary system imaging. You say that hepatobiliary system imaging is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says hepatobiliary system imaging 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve hepatobiliary system imaging. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no evidence in the provided records of gastrointestinal symptoms, or 
of hepatobiliary disease, specifically. There is no indication for performing the requested study. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hepatobiliary system imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hepatobiliary system imaging (78227).
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 your  transmitter is not working 
correctly and you need another one early. The Plan denied your request. The Plan says that you are requesting a 
CGM product that does not meet Medicare's definition of durable medical equipment (DME) and, therefore, is 
not in a defined Medicare benefit category. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. 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 pay for prophylaxis - adult (D1110) provided on November 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that due to your health situation, your provider 
suggested you get three to four cleanings a year. You say that even though your insurance covers two per year, 
you would like to be approved for more. 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. This benefit includes the 
requested prophylaxis - adult (D1110) but is limited to two every calendar year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered prophylaxis - adult D1110 on February 1, 2022, and on May 3, 2022. Therefore, 
this benefit has been exhausted as of November 14, 2022. Therefore, we decided that the Plan does not have to 
pay for prophylaxis - adult (D1110) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) on tooth # 18. 
 
You asked the Plan to pre-approve a crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not indicate the criteria was met. Specifically, documentation 
provided does not demonstrate that there is pathologic destruction to the tooth by caries or trauma involving 4 
or more surfaces and at least two cusps. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the documentation indicates the presence of a 
large restoration and distal fracture of tooth #18. It is medically reasonable and necessary to place a crown 
restoration to prevent further fracture and to provide good masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown (D2740) on tooth # 18.  
 
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 pay for fixed wing air transport (A0430) and fixed wing air mileage 
(A0435) provided on July 19, 2022. You asked the Plan to pay for the fixed wing air transport and air mileage. You say that based on the clinical 
information documented this transport meets medical necessity guidelines. The Plan denied your request. The 
Plan says the air transport services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 fixed wing air transport and air mileage. 
Our reviewer says that the air ambulance services was not medically necessary. Our physician reviewer found 
the documentation does not sufficiently support that the enrollee's condition was such that the time needed to 
transport a patient by ground, or the instability of transportation by ground, posed a threat to survival or 
seriously endangered health. 
 
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 fixed wing air transport and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for fixed wing air transport (A0430) and fixed wing air mileage 
(A0435) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on December 3, 2022, from an out-
of-network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that you used a less expensive provider, and this should 
be covered. The Plan denied your request. The Plan says eyeglasses are not covered when purchased from a 
provider that is out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses purchased on December 3, 2022, from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D4263) provided on July 20, 2022. 
 
You asked the Plan to pay for a bone replacement graft. 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 pay for a bone 
replacement graft (D4263) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that if you cannot get 
additional rides, then you will have to change your plans. The Plan denied your request. The Plan says that the 
benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit documentation showing that you have used 48 one-way 
non-emergency transportation trips. This means we are unable to determine if the denial is correct. Therefore, 
we decided that the Plan has to pre-approve the additional routine transportation trips.  
 
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 intraoral - complete series of radiographic image (D0210) 
provided on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider made you get an x-ray that was not 
covered, so you should not have to pay for the x-ray. 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. This benefit includes the 
requested intraoral - complete series of radiographic image (D0210) but is limited to one procedure code every 
five calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0210 on August 30, 2021. Therefore, this benefit was exhausted as of February 
2, 2023. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic 
image (D0210) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a cleaning (D1110) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are confused by the per year limitation and 
you would like the claim paid. The Plan denied your request. The Plan says that your benefit for the requested 
item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
for a cleaning on April 5, 2022, and the benefit for a cleaning is 1 every 6 months; therefore, October 5, 2022, 
would be the next eligible date for another cleaning which is earlier then the date of service of October 11, 
2022. There is no evidence showing your benefit for the requested item or service was previously exhausted. 
Therefore, we decided that the Plan has to pay for a cleaning (D1110) provided on October 11, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (procedure code G0483) 
rendered on December 15, 2022. 
 You asked the Plan to pay for the testing. You say that this was ordered by a treating physician based on 
medical necessity. The Plan denied your request. The Plan says each individual definitive drug class tested 
must be medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation does not clearly show a screening test with results displaying 
inconsistent or unexpected results to justify follow-up confirmation/definitive testing. A review of the 
enrollee's records did not reveal that all of the 22 drug classes tested were applicable to this case, such as the 
enrollee already taking them or with suggestion of them taking the drug without a prescription.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (procedure code G0483) rendered on December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 Reader. You say that you need this to help you with 
your type 2 diabetes. The Plan denied your request. The Plan says you are not receiving insulin and have not 
had a documented hypoglycemic episode, so the continuous glucose monitor is not medically necessary and not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable 
and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for  
coverage of the FreeStyle Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a FreeStyle Libre 2 Reader.