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

 
We decided that the Plan has to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you have continued to see this patient 
since 2000 when she had corneal transplant surgery on left eye. The enrollee has been scheduled every 6 
months to 1 year for follow ups for numerous corneal issues including corneal graft rejection, and keratitis. The 
Plan denied your request. The Plan says that each one-way trip must not exceed 50 miles of driving distance. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the 
Plans rules for coverage of additional mileage have been met. One route shows the distance requested appears to be 
less than 50 miles one way. Therefore, we decided that the Plan has to pre-approve additional mileage.  
 
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 the Sprint peripheral nerve stimulator (PNS) system 
(64555 x2, C1778 x2, 76942 x2, 95972 x2). 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Sprint PNS System in the setting 
of gluteal pain, has not been demonstrated in the peer-reviewed literature. 
 
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 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 the Sprint PNS device is experimental for gluteal buttock pain. More research is 
needed.  
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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system (64555 x2, C1778 x2, 76942 
x2, 95972 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided from 
March 17, 2023, to April 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they are 
excluded from Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided from March 17, 2023, to April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 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 72 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 routine transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on March 14, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you should not 
owe an additional copayment for returning to the ER within 24hrs of the first visit. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for each emergency room (ER) visit. This item/service falls 
within the emergency care 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 each 
emergency room (ER) visit provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for denture relining services (D5730) 
provided on June 7, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 a 50% coinsurance for denture relining services. This item/service falls within the 
comprehensive dental service 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 coinsurance for denture 
relining services (D5730) provided on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on May 8, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6545 that were issued on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, pontic, and retainer crown (D6752, 
D6242, D2950) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 April 5, 2023. Therefore, 
we decided that the Plan does not have to pay for core buildup services, pontic, and retainer crown (D6752, 
D6242, D2950) provided on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain crown (D2750) provided on April 21, 2022. 
 
You asked the Plan to pay for porcelain crown (D2750). You say that you were not aware about the coverage 
changing from Plan dental vendors leading to now you are getting denial of coverage. You also say no one told 
you about this. The Plan denied your request. The Plan says this is not a covered benefit on your 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 pay for porcelain 
crown (D2750) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mandibular partial denture - cast metal framework 
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on March 
15, 2023. 
 
You asked the Plan to pay more for the mandibular partial denture. You say that your sales agent indicated that 
your dentist is in-network with your plan. 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 mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
on March 15, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a low frequency, non-contact, non-thermal ultrasound (97610). 
 
You asked the Plan to pre-approve a low frequency, non-contact, non-thermal ultrasound. You say that you 
need this treatment because you have been dealing with pain of the wound between your toes for three to four 
months, and it has not gotten any better. The Plan denied your request. The Plan says that the notes show you 
do not meet criteria and further medical necessity is not present. 
 
The Plan follows Medicare rules. Medicare rules say that Low-Frequency, Non-Contact, Non-Thermal 
Ultrasound is considered reasonable and necessary wound therapy and therefore eligible for coverage by 
Medicare when provided for any of the clinical conditions listed in the Medicare rules section of this letter. 
 
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 low frequency, non-contact, non-
thermal ultrasound. Our reviewer says that you do have a condition which is indicated for coverage of low-
frequency, non-contact, non-thermal ultrasound debridement. Our physician reviewer found the medical 
documentation supports that you are suffering with a non-healing, very painful ulceration to the fourth digit left 
side. The pain is so great that it is unable to be debrided mechanically and sharply. Our reviewer found that you 
are undergoing wider shoe gear treatment, offloading of the area, and dressing changes. Our reviewer also 
found that the ulceration is not improving according to the wound measurements noted in the chart notes. 
 
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 low frequency, non-contact, non-thermal ultrasound have been met. 
Therefore, we decided that the Plan has to pre-approve a low frequency, non-contact, non-thermal ultrasound 
(97610).  
 
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 the intraoral - periapical each additional radiographic image 
(D0230) provided on May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider agreed to only perform covered 
services during the exam and cleaning. The Plan denied your request. The Plan says your benefit for the 
intraoral - periapical each additional radiographic image  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 intraoral - periapical each additional radiographic image was exhausted on date of 
service May 4, 2023. You already received the allowed frequency of 1 (D0220) intraoral - periapical first 
radiographic image on the appealed claim. Therefore, we decided that the Plan does not have to pay for the 
intraoral - periapical each additional radiographic image (D0230) provided on May 4, 2023.  
 
Your complaint about the dental practice is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
requested scan. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee does not have a 20 pack-year smoking 
history. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided on June 1, 2023. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation. You say that while you were at 
the dentist, he stated that he was going to have to drill this out. You also say that there was no alternative to 
your knowledge and you were not informed that it would not be covered. The Plan denied your request. The 
Plan says if you receive a service not listed in the medical benefits  table, you will have to pay the full cost. 
 
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 bone 
replacement graft for ridge preservation - per site (D7953) provided on June 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation services. 
 
You asked the Plan to pre-approve additional transportation services. You say that the services are medically 
necessary for you to receive physical therapy services for your feet. The Plan denied your request. The Plan 
says you have exceeded your yearly benefit. 
 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 36 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 transportation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs received on May 1, 2023, to 
May 2, 2023. 
 
You asked the Plan to pre-approve the medication. You say that the services were medically necessary. 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 the self-administered drugs 
received on May 1, 2023, to May 2, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on February 23, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the enrollee was advised by the doctor to have 
the dental service done before her knee replacement surgery. The Plan denied your request. The Plan says your 
benefit for the requested 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 prophylaxis - adult was exhausted on date of service September 22, 2022.  Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on 
February 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on March 
31, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that it was unnecessary for 
you to go to the hospital. The Plan denied your request. The Plan says only when you are transported by 
ambulance the service is payable. 
 
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 March 31, 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 without transport services received 
on March 31, 2023.