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

 
We decided that the Plan does not have to pay for the amalgam - three surfaces, primary or permanent (D2160), 
resin-based composite - two surfaces, anterior (D2331), resin-based composite - three surfaces, anterior 
(D2332), resin-based composite - two surfaces, posterior (D2392), and protective restoration (D2940) provided 
on June 27, 2023, to August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why your dental claims 
were not covered when you have a dental plan. The Plan denied your request. The Plan says these services are 
not a covered benefit under your dental plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam - 
three surfaces, primary or permanent (D2160), resin-based composite - two surfaces, anterior (D2331), resin-
based composite - three surfaces, anterior (D2332), resin-based composite - two surfaces, posterior (D2392), 
and protective restoration (D2940) provided on June 27, 2023, to August 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that most of your specialists are beyond the 
50-mile limit, and you need the transportation. The Plan denied your request. The Plan says the additional 
mileage exceeds the benefit's limit. 
 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 a trip is within the 50-mile limit.  
 
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 routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (64640). 
 
You asked the Plan to pre-approve destruction by neurolytic agent; other peripheral nerve or branch. You say 
that this is medically necessary. The Plan denied your request. The Plan says this is considered investigational 
and is not covered. 
 
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 destruction by neurolytic agent; other 
peripheral nerve or branch. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this would be considered experimental 
therapy for knee osteoarthritis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent; other peripheral nerve or branch have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent; other 
peripheral nerve or branch (64640).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 2, 2023. You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the requested service is not a Medicare -covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on August 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 11, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you cannot afford the 
bill. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit 
and without a transport there is no payable service. 
 
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 July 11, 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 ambulance treatment without transport provided 
on July 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of both breasts. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee is in pain and is concerned because they 
have a family history of death due to breast cancer. The Plan denied your request. The Plan says the 
documentation does not support any suspicious findings. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found additional testing such as a whole breast 
ultrasound is indicated due to the extremely dense tissue on the mammography. There is incomplete 
information concerning the valid indication for a breast MRI. The MRI cannot be approved 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of both breasts.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on October 16, 
2022. 
 
You asked the Plan to pay for the non-emergent services. You say that you cut your foot on a piece of glass and 
were advised by the ambulance crew to go to the emergency room. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found you were transferred to and 
from the emergency department for foot pain. You were able to ambulate and were alert and oriented. Other 
forms of transport were not contraindicated. 
 
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 non-emergent services have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance services provided on October 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture reline (D5750) provided on 
August 17, 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 August 10, 2023. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture reline (D5750) 
provided on August 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan 
says this is not medically necessary because based on the medical literature this procedure is considered 
experimental or investigational and has not been proven to be beneficial for your condition. 
 
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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve ablations are considered investigational and not medically 
necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, 
when performed (64454).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM), supplies and accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that it is in the enrollee's best 
interest to monitor daily blood sugars more closely. You also say that the Dexcom CGM system would better 
allow this without the hassle of pain and traditional finger sticks. The Plan denied your request. The Plan says 
that based on Medicare guidelines, the request for the medical device used to continuously check blood sugar 
and related supplies do not meet the requirements for approval.  
 
The Plan must follow 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 the CGM, supplies and accessories. Our 
reviewer says that these items are medically necessary. Our physician reviewer found the enrollee has had low 
blood glucose sugar, is unable to see a standard glucometer and is on a medication that can cause low blood 
glucose sugar, it is reasonable to use a CGM as her medical doctor writes in a letter. 
 
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 CGM, supplies and accessories have been met. Therefore, we decided that 
the Plan has to pre-approve a continuous glucose monitor (CGM), supplies and accessories.  
 
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: 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 needs the IRF to help with their 
recovery. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 and/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 as 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional rental months of the oxygen concentrator 
and the portable gaseous system provided on October 9, 2022, to, November 9, 2022.  
 
You asked the Plan to pay for the two additional rental months of the oxygen concentrator and the portable 
gaseous system. The Plan denied your request. The Plan says that the number of visits exceeded the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator and the portable gaseous system have not been met. Specifically, the 
provider billed for 46 rental months, which is not allowed. Therefore, we decided that the Plan does not have to 
pay for the two additional rental months of the oxygen concentrator and the portable gaseous system provided 
on October 9, 2022, to, November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
September 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that your dentist was unable to be reached for 2 
weeks so you had to find a new dentist for some problems of pain and bleeding around your lower front teeth. 
You also say that this is the first time you have seen this provider and x-rays were needed to find out the nature 
of the problem. 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 requested service was exhausted on date of service September 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
September 5, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cryoablation (20983). 
 
You asked the Plan to pre-approve cryoablation. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. More medical research is needed to support this is 
safe and effective for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 cryoablation. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the request for cryoablation therapy is the best option for this patient when considering his 
diagnosis and prior radiation therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cryoablation have been met. Therefore, we decided that the Plan has to pre-
approve cryoablation (20983).  
 
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 transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. 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 transurethral waterjet ablation of prostate 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found 
the records show that the maximum urinary flow rate (Qmax) is not less than or equal to15 milliliters. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a reline complete mandibular denture (indirect) 
(D5751) provided on July 5, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were informed on a call with the plan 
representative that no payment was made for procedure D5751. You also say that you understand your dental 
allowance is $1000 annually and believe that payment should be made for procedure D5751, given this 
information. 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 a reline complete mandibular denture 
(indirect) (D5751) provided on July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 You asked the Plan to pre-approve transurethral waterjet ablation of prostate. 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 transurethral waterjet ablation of prostate 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 transurethral waterjet ablation of 
prostate. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found 
the enrollee has not failed at least three months of conventional medical therapy as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).