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

 
We decided that the Plan does not have to pay for the osseous surgery (D4260) and guided tissue regeneration 
(D4266 x 3) provided on March 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed these specific 
procedures would not be covered. The Plan denied your request. The Plan says these services are not covered 
under the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
osseous surgery (D4260) and guided tissue regeneration (D4266 x 3) provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 23, 2023. 
 
You asked the Plan to pay for an eye refraction (92015). You say that this service was a routine diagnosis. You 
also say that the provider required this before your cataract surgery. The Plan denied your request. The Plan 
says the provider performed these services for the member as a result of a medical diagnosis, not as part of a 
routine examination. The Plan also says that this effectively precludes the service from coverage. 
 
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 they are part of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that original Medicare does not cover routine eye 
examinations (eye refractions). The Plan contract also says that routine (refractive) eye examinations are 
limited to one examination every two calendar years. Medical diagnostic refractions are not covered under the 
Plan benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction 
(92015) have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
(92015) provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 3 sensors.  
You asked the Plan to pre-approve the FreeStyle Libre Kit 3 sensors. You say that the enrollee is also on 
Omnipod and needs this for blood glucose testing. The Plan denied your request. The Plan says criteria for 
medical necessity have not been 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 the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the FreeStyle Libre Kit 3 sensors have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 3 sensors.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the correction of trichiasis (67820) 
provided from January 24, 2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for the correction of trichiasis (67820). You say that this should be 
covered because you must have this lash removal procedure done every five weeks as it blocks your vision and 
is medical. 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 $40 
copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye.  
 You have been asked to pay $19.19, which is less than the $40 copayment for each visit of the correction of 
trichiasis (67820). This item/service falls within the Medicare-covered outpatient visit for services to diagnose 
and/or treat a disease or condition of the eye 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 correction of trichiasis (67820) provided from January 24, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. 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 an office visit provided 
on February 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on February 28, 2023. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says records do not show the enrollee meets Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
  We looked at the file and Medicare rules. A requested was made for medical records from your provider but 
they were not received, and without medical records we cannot determine whether you meet the criteria for 
foot orthotics. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of foot orthotics have been met. Therefore, we decided that the Plan 
does not have to pay for foot orthotics provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) and the placement of 
biological dressing (D7922) for tooth #7 and #11 provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the previous dentures that you had do not fit in 
your mouth. The Plan denied your request. The Plan says your benefit for the complete lower denture has 
already been exhausted. Also, the denial of payment for the placement of biological dressing is correct because 
it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete lower denture (D5120) on February 28, 2020; therefore, your benefit for the 
complete lower denture was exhausted on the date of service of February 28, 2020. The placement of biological 
dressing is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a complete lower denture (D5120) and the placement of biological dressing (D7922) for tooth #7 and 
#11 provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 18, 2023. 
 
You asked the Plan to pay for telehealth services. You say that it is the responsibility of the facility to obtain 
authorization. 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 telehealth services 
provided on February 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on February 25, 2023. 
 
You asked the Plan to waive the deductible for an office visit. You say that you want to appeal the amount 
being charged. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on January 25, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit on February 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 16, 2023. 
 
You asked the Plan to pay for lab testing. You say that you believe the services are medically necessary. 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 lab testing provided on 
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 01, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on February 01, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is highly motivated, able, and willing to 
participate in the required therapy provided at an IRF. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee's low back pain continues to affect 
their activities of daily living. You say that the enrollee feels fatigue and has difficulty with prolonged walking. 
The Plan denied your request. The Plan says a transforaminal epidural steroid injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee underwent a 
transforaminal epidural steroid injection at the L3 level on June 22, 2023, with 5 % improvements in their 
symptoms. However, the LCD criteria requires 3 months of 50% pain relief to repeat the ESI. Additionally, if a 
different route or different medications are trialed then a repeat ESI could be performed. Therefore, the request 
is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transforaminal epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says 
the radiofrequency ablation 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 the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary.  Our physician reviewer found that 
the enrollee has bilateral sacroiliitis and has had a SIJ ablation over 2 years ago with the pain recently 
returning. However, the request is considered experimental because of the wide variation in efficacy that was 
reported. Therefore, the request is not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for CT Chest. Has not had plain chest radiograph 
done yet, or at least non-documented. 
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a chest x-ray is meaningless since even if 
normal CT would still be indicated. The request for CT of the chest (71250) is reasonable and should be 
approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT scan).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS) system (64555 
x2). 
 
You asked the Plan to pre-approve Sprint PNS system. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Sprint PNS system in the setting of 
lower back pain have not been demonstrated in the peer-reviewed literature. There are limited published studies 
that show this to be an effective and/or safe treatment. 
 
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 Sprint PNS system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Sprint PNS is the subject of an ongoing clinical trial for low back pain. It is 
considered experimental/investigational at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Sprint peripheral nerve stimulator (PNS) system (64555 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve submucosal ablation of the tongue base (41530). 
 
You asked the Plan to pre-approve submucosal ablation of the tongue base. You say that this is medically 
necessary. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 submucosal ablation of the tongue base. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found as of now there are limited low-quality studies that fail to clearly show 
long-term safety and efficacy of the ablation procedure to fully support this request at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of submucosal ablation of the tongue base have not been met. Therefore, we 
decided that the Plan does not have to pre-approve submucosal ablation of the tongue base (41530).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
clearly evident regarding worsening pain. There is no indication of a progression of the body height loss, 
greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on the enrollee's daily 
activities. Moreover, there is magnetic resonance imaging corroboration of other plausible causes of the lumbar 
pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).