Persius/hicric huggingface dataset:
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 a Freestyle Libre 3 Sensor. You say that the requested item is medically 
necessary for the enrollee. The Plan denied your request. The Plan says Freestyle Libre 3 is not currently 
eligible for Medicare reimbursement; therefore, we are unable to approve your coverage request. 
 
The Plan follows Medicare rules. The 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 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 Freestyle Libre 3 Sensor. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the review has 
determined that the member has diabetes mellitus and is insulin treated with three or more daily administrations 
of insulin. The enrollee's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis 
of blood glucose meters (BGM) or CGM testing results. The non-preferred CGM product you requested 
requires that there is a clinical rationale why the preferred product, Freestyle Libre 2, is not clinically 
appropriate for the member and that the non-preferred CGM is covered by Medicare. 
 
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 Freestyle Libre 3 Sensor have not been met. 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 the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), pulp vitality tests (D0460), and the cone beam computed 
tomography (CT) capture and interpretation with limited field of view-less than one whole jaw (D0364) 
provided on March 31, 2023. 
 
You asked the Plan to pay 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 your benefit for the limited oral evaluation and the intraoral-periapical first radiographic image 
provided has already been exhausted. Additionally, pulp vitality tests and the cone beam computed tomography 
(CT) capture and interpretation provided are not covered.  
 
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 limited oral evaluation and intraoral-periapical x-ray provided was exhausted on 
date of service March 14, 2023. Specifically, the Plans contract states that one limited oral evaluation and  
intraoral-periapical x-ray are covered every year. You previously received these dental services on March 14, 
2023; therefore, you have exhausted the allowable benefit for these services. Additionally, pulp vitality tests 
and a cone beam CT scan are not covered. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image (D0220), pulp 
vitality tests (D0460), and the cone beam computed tomography (CT) capture and interpretation with limited 
field of view-less than one whole jaw (D0364) provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0210) provided April 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that no one has ever sent you a book or information 
to inform you that x-rays are only paid every three years. 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 22, 2021. Therefore, we decided that the Plan does not have to pay for intraoral radiographic images (D0210) provided 
April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) and the periodic oral 
evaluation (D0120) provided on March 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) and the periodic 
oral evaluation (D0120) provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation for deep sedation or general anesthesia 
(D9219). 
 
You asked the Plan to pre-approve evaluation for deep sedation or general anesthesia. You say that this should 
be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
evaluation for deep sedation or general anesthesia (D9219).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425, A0422) provided 
on February 22, 2023. 
 
You asked the Plan to pay for ambulance transportation. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A0428, A0425, & A0422 are not supported in the medical record. Specifically, 
diagnosis code S09.90XS is a sequela code and not a valid primary diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance transportation (A0428, A0425, A0422) provided on 
February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the porcelain/ceramic crown (D2740) provided on November 3, 2022. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that your benefit for the dental item provided 
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 has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, the Plan has not provided substantive evidence that demonstrates your benefit 
for the dental item provided was previously exhausted. The Plan has not substantiated their denial; therefore, 
we must find in your favor. Therefore, we decided that the Plan has to pay for the porcelain/ceramic crown 
(D2740) provided on November 3, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements 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 an epidural steroid injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee's pain 
radiates to his shoulder which corresponds to the area of spinal stenosis. The request is deemed 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection (62321).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 90792 billed with diagnosis 
codes F12.959 and F12.20 provided from February 8, 2023, to February 13, 2023. 
 
You asked the Plan to pay for procedure codes 99285 and 90792. 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 health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes F12.959 and F12.20 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99285 and 90792 billed with diagnosis codes F12.959 and F12.20 provided 
from February 8, 2023, to February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the podiatry services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the podiatry services. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says this service was not authorized. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the podiatry services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state provided on April 17, 
2023. 
 
You asked the Plan to pay for a determination of refractive state. You say that you are appealing with 
supporting records. 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 determination of 
refractive state provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the prefabricated abutments-includes 
modification and placement (D6056 x 3), the abutment supported porcelain/ceramic crowns (D6058 x 3), and 
the dental cleaning (D1110) provided on November 1, 2022 and November 21, 2022. 
 
You asked the Plan to issue reimbursement for the dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the dental items/services provided 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 dental items/services provided was exhausted on date of service May 26, 2022. 
Specifically, the Plans maximum allowable dental coverage per year is $1,800. The Plan issued payment in the 
amount of $1,800 ($1,056 + $372 + $372) for the services provided on May 26, 2022. Therefore, you have 
exhausted the maximum allowable dental benefit for the 2022 calendar year. Therefore, we decided that the 
Plan does not have to issue reimbursement for the prefabricated abutments-includes modification and 
placement (D6056 x 3), the abutment supported porcelain/ceramic crowns (D6058 x 3), and the dental cleaning 
(D1110) provided on November 1, 2022 and November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) and to 
pay more for a partial lower denture (D5214) provided on February 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you only went to get 1 tooth replaced on your 
partial and would like for it to be paid. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year 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 the Plan paid $2,000 for dental services on February 6, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of February 6, 2023. Therefore, we decided 
that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) and to pay more for 
a partial lower denture (D5214) provided on February 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide. 
 
You asked the Plan to pre-approve home health aide. You say that you need help with your personal care and 
medication. The Plan denied your request. The Plan says the request does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health 
aide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), surgical placement 
of implant body (D6010) and a bone graft (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the implants has already been exhausted. Guided tissue 
regeneration and a bone graft are only covered when placed within 6 months of an extraction. The last 
extraction done was over 6 months ago. 
 
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 implants was exhausted. Therefore, we decided that the Plan does not have to pre-
approve guided tissue regeneration (D4266), surgical placement of implant body (D6010) and a bone graft 
(D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 and supplies.. You say that the requested items are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria. 
 
The Plan follows Medicare rules. The 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 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 Freestyle Libre 2 and supplies. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is not on 
medications that should cause low blood sugars and is not using insulin. Also, we have not been told why the 
enrollee cannot use a glucometer. Therefore, criteria for a CGM has not been met. 
 
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 Freestyle Libre 2 and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre 2 and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arikayce. 
 
You asked the Plan to pre-approve the medication. You say that Arikayce is 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 Arikayce.   
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, conventional air services, transport, one way, and 
air mileage provided on September 17, 2022. 
 
You asked the Plan to pay for the ambulance air transport service and air mileage. You say that this was a 
medically necessary emergency transport. The Plan denied your request. The Plan says that according to our 
records the precertification entity was not contacted for precertification. 
 
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. Specifically, the Plan did not review their appeal as the time frame was missed 
and they failed to provide a valid denial rationale for emergency ambulance services. The Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pay for ambulance service, 
conventional air services, transport, one way, and air mileage provided on September 17, 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.