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

 
We decided that the Plan does not have to pre-approve a dual chamber pacemaker (33208). 
 
You asked the Plan to pre-approve a dual chamber pacemaker. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers are covered under certain circumstances. 
 
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 dual chamber pacemaker. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac pacemaker in this enrollees clinical 
management. 
 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 dual chamber pacemaker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a dual chamber pacemaker (33208).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT services are medically 
necessary. The Plan denied your request. The Plan says the requested PT services are not reasonable and 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. There is no documentation of a recent injury or 
decline in function. The additional therapy services are not an appropriate duration and frequency for treatment 
of the members medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that this drug 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 Ozempic.   
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 pre-approve cone beam CT (D0364) and prefabricated post and core 
in addition to crown (D2954). 
 
You asked the Plan to pre-approve cone beam CT and prefabricated post and core in addition to crown. 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 cone 
beam CT (D0364) and prefabricated post and core in addition to crown (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the resin-based composite-four or more surfaces or 
involving an incisal angle (anterior) (D2335) provided on May 4, 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 limited oral evaluation-problem focused 
(D0140), intraoral-periapical first radiographic image (D0220), and the resin-based composite-four or more 
surfaces or involving an incisal angle (anterior) (D2335) provided on May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 2 sensor kit and reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit and reader. You say that a Freestyle Libre 2 
sensor kit and reader is medically necessary. The Plan denied your request. The Plan says that a Freestyle Libre 
2 sensor kit and reader is not medically necessary. 
 
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 a Freestyle Libre 2 sensor kit and 
reader. Our reviewer says that you need this medical item. Our physician reviewer found the enrollee is using 
insulin since June 2023; Therefore, the enrollee meets criteria for CGM coverage 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 a Freestyle Libre 2 sensor kit and reader have been met. Therefore, we decided 
that the Plan has to pre-approve a Freestyle Libre 2 sensor kit and reader.  
 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 hospital services provided on January 18, 2023. 
 
You asked the Plan to pay for the hospital services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 the billed services are not supported in the medical record. Specifically, the patient was admitted 
on January 19, 2023 as an inpatient. The pre-admission services are included in the inpatient payment. Based 
on this information, we decided that Medicare rules for coverage of the hospital services have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital services provided on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (E0731 and A4595) provided 
on March 14, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment (E0731 and A4595) provided on 
March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the items denied correctly as the enrollee does not 
meet the clinical requirements to be approved. 
 
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. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found that coverage criteria for the CGM requires 
insulin use or low blood glucose levels (BGS); The record indicates the enrollee is using a basal insulin daily to 
control BGS; hence coverage criteria for CGM are 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 the CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
 
  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 more for adult prophylaxis (D1110) provided on March 31, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you went to an out-of-network dentist and 
had to pay upfront. 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 adult prophylaxis (D1110) provided on 
March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on February 13, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not 
support the billing of procedure codes 96365, 96366, 96521, and J1817. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96365 is Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is Refilling and maintenance of portable pump. The definition of code J1817 is Insulin for administration through dme (i.e., 
insulin pump) per 50 units. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate code than 96365, 96366, and 96521 for these services. The file shows that Novolin R was 
administrated intravenously as part of OIVIT and there is a more appropriate code than J1817 for this service. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 
provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that you disagree with the denial and request 
reconsideration due to cancer diagnosis. The Plan denied your request. The Plan says there is not enough 
research showing that the enrollee's type of cancer responds better to the requested type of treatment than the 
type of treatment the Plan can approve. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, which has proven efficacy and 
tolerability. Certain conditions such as base of skull chordomas and chondrosarcomas, and pediatric central 
nervous system (CNS) malignancies are probably best treated with proton therapy, due to the sharp dose fall 
off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. There is 
no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of 
definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive 
therapy. Nothing in the case file suggests that standard dosimetric constraints cannot be met with a non-proton-
based treatment, and it is not plausible that proton therapy would be needed to meet these constraints. Proton 
therapy will almost always reduce dose to surrounding normal tissues. While National Comprehensive Cancer 
Network (NCCN) guideline consider proton therapy a reasonable alternative they do not describe it as being 
necessary in lieu of non-proton-based treatment and are quite explicit in that there is no evidence of its 
superiority. The decision is unfavorable as the reviewer does not believe the LCD criteria is 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 11 (D2740) 
and clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve this dental item/service. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested dental item 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 dental crown was exhausted on date of service October 2, 2018.  
  
 
 
 
 
Specifically, the Plans contract states that a dental crown is covered once every 60 months. You previously 
received a dental crown on October 2, 2018, less than 60 months prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this dental item. Additionally, as you are not eligible 
for the dental crown requested in this case at this time, clinical crown lengthening would not be necessary. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth number 
11 (D2740) and clinical crown lengthening (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the removal of benign odontogenic cyst or tumor 
(D7450) and the removal of impacted tooth (D7240) provided on October 25, 2022. 
 
You asked the Plan to reimburse for the removal of benign odontogenic cyst or tumor (D7450) and the removal 
of impacted tooth (D7240). You say that you paid the amount in full and believe you should be compensated 
for your coverage of the $800. The Plan denied your request. The Plan says you got the service from a provider 
who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse for the 
removal of benign odontogenic cyst or tumor (D7450) and the removal of impacted tooth (D7240) provided on 
October 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on March 
25, 2023. You asked the Plan to pay for the non-covered ambulance mileage. You say that you requested 
transport to the facility where you had a recent aortic valve replacement surgery. You also say that the closer 
hospital did not have a transcatheter aortic valve replacement (TAVR) team to treat you. The Plan denied your 
request. The Plan says the additional transport mileage was not medically necessary. There are more than three 
emergency room facilities closer to the enrollee's residence who could have evaluated and transported you to 
your requested facility if needed. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport is covered to the nearest 
appropriate facility equipped to treat the patient.  
 
We looked at the file and Medicare rules. The records show that you were transported to a hospital that was not 
the nearest appropriate facility to obtain necessary care. There were closer facilities that were equipped to 
provide the needed hospital care to treat the enrollees condition at the time. The records provided do not 
demonstrate that your condition required a higher level of trauma care or other specialized service that was 
only available at the more distant hospital. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for non-covered ambulance mileage (A0888) provided on March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown -porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve a crown. 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 
crown -porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix blood glucose test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve True Metrix 
blood glucose test strips.