Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a non-invasive 
ventilator (NIV) (E0466). 
 
You asked the Plan to pre-approve 9 months continued use of a NIV. You say that the enrollee is at high risk 
for hospital readmission and potentially life-threatening exacerbation. The Plan denied your request. The Plan 
says the request for continued use of a NIV is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 9 months continued use of a NIV. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does have 
COPD with chronic respiratory failure and is prescribed and compliant and benefiting from bilevel positive 
airway pressure (BIPAP) therapy. She is meeting her goals and tolerating, as well as thriving with this therapy 
and does not require a NIV with Trilogy therapy at this time as she has not failed BIPAP therapy. In fact, she is 
doing quite well with the current therapies and modalities per documentation. There is no data documented to 
support otherwise. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 months continued use of a NIV have not been met. Therefore, we decided that 
the Plan does not have to pre-approve nine (9) months continued use of a non-invasive ventilator (NIV) 
(E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140) provided on December 15, 2022. 
 
You asked the Plan to pay for the extraction. You say that you had to have this procedure as you had a cracked 
tooth and this was considered a medical emergency The Plan denied your request. The Plan says this service is 
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  service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says there was insufficient medical information provided to review the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a broken complete upper denture (D5512) 
provided on April 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had question about the bill for the denial 
claim and you did not have any other charges for your dentures. 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 the Plan paid for the repair of a broken complete upper denture (D5512) on April 22, 2021; therefore, 
your benefit for the requested item or service was exhausted on the date of service of April 22, 2021. 
Therefore, we decided that the Plan does not have to pay for the repair of a broken complete upper denture 
(D5512) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on April 18, 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 the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services (D2950) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM provided on March 2, 2023. 
 
You asked the Plan to pay for a CGM. You say that you do not agree with the denial of payment. The Plan 
denied your request. The Plan says no prior authorization was received. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for durable medical equipment (DME) item(s) that cost more than 
$1,000. 
 
The requested provider in this case did not send in a prior authorization to the Plan. The Plan did not pre-
approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the CGM provided on March 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a determination of refractive state (92015) provided on 
April 14, 2023 
 
You asked the Plan to reimburse for a determination of refractive state (92015). You say that as an individual 
with hypertension, a thorough yearly examination is appropriate for monitoring ocular status. The Plan denied 
your request. The Plan says the provider confirmed that the member was seen for medical related concerns and 
with a medical diagnosis. The Plan also says that eye refractions are only covered by your plan if performed by 
a participating Plan provider and performed during a routine eye examination.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions). The Plan rules also say that they cover eye refractions during a routine 
examination. The record shows this was a medical/diagnostic eye refraction and not a routine eye examination. 
Based on this information, we decided that the Plan's rules for coverage of a determination of refractive state 
(92015) have not been met. Therefore, we decided that the Plan does not have to reimburse for a determination 
of refractive state (92015) provided on April 14, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine continuous glucose monitoring (CGM) sensors. 
 
You asked the Plan to pre-approve twelve additional CGM sensors. You say that the enrollee needs these 
additional CGM sensors which is supported by the medical records. The Plan denied your request. The Plan 
says the enrollee currently uses a FreeStyle Libre 2 sensors and reader and one sensor can be used a maximum 
of 14 days, so in 30 day period 2 sensors are required. 
 
The Plan follows Medicare rules. Medicare rules say that the supply allowance (code A4238 or A4239) is 
billed as one (1) unit of service (UOS) per thirty (30) days. Only one (1) UOS of code A4238 or A4239 may be 
billed to the DME MACs at a time 
 
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 additional CGM sensors. Our 
reviewer says that the additional CGM sensors are not medically necessary.  Our physician reviewer found based on the medical records provided there is no documentation that the nine 
additional CGM sensors at issue in this case meets all Medicare criteria for medically reasonable and necessary 
for the enrollee.  
 
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 additional CGM sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine continuous glucose monitoring (CGM) sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210), and comprehensive oral evaluation - new or established patient (D0150) provided on March 9, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images and comprehensive oral 
evaluation. You say that you do not believe that you should pay this bill because you used the amount due to 
you from your policy. The Plan denied your request. The Plan says your benefit for the requested services $300 
dollar limit was met. 
 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 - complete series of radiographic images was exhausted on date of service 
March 4, 2021. The record also shows that the Plan has provided evidence of having made payments totaling 
$300 towards the cost of dental services provided in 2023.  
 
Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of radiographic 
images (D0210), and comprehensive oral evaluation - new or established patient (D0150) provided on March 9, 
2023.  
 
Your complaint about the treatment you received from the dentist 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), provided on May 
2, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 December 28, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
provided on May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341-26 and 88342-26 billed for date of 
service October 20, 2022. 
 
You asked the Plan to pay for procedure codes 88341-26 and 88342-26. You say that the number of units 
provided was medically necessary. The Plan denied your request. The Plan says payment for codes 88341-26 
and 88342-26 are bundled into payment for code 88360. 
 
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, we have confirmed that codes 88341-26 and 88342-26 are column II codes to column I code 
88360. The codes at issue have not been billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88341-26 and 88342-26 billed for date of service October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implanted subcutaneous cardiac monitor 
(implantable loop recorder [ILR]). 
 
You asked the Plan to pre-approve the ILR device. You say that the guidelines support coverage for scenarios 
of cryptogenic stroke as well as management of atrial fibrillation. You also say that this should be approved. 
The Plan denied your request. The Plan says this device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder (ILR) is used when 
syncope is thought to be cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. Therefore, the requested insertion of an ILR is not medically reasonable or 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 ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implanted subcutaneous cardiac monitor (implantable loop recorder [ILR]).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6061), provided on April 13, 2023. 
 
You asked the Plan to pay for D6057 and D6061. You say that you assumed implants were covered. The Plan 
denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057), and an abutment supported crown (D6061), provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve waterproof tape (A4452 x720 units). 
 
You asked the Plan to pre-approve waterproof tape. You say that the tape is medically necessary and you 
would like to appeal the denial. The Plan denied your request. The Plan says this request exceeds the allowed 
amount per month by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of waterproof tape have not been met. Therefore, we decided that the Plan does not have to pre-
approve waterproof tape (A4452 x720 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service February 27, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that medical records were 
provided. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 are 
bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that a urinary tract infection panel was provided. In this case, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. The codes at issue were billed with the 
XU modifier. The records provided did show the services were distinct components of the main service. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 87481, 87653, and 87798 billed for date of service February 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was a 
medical condition and should be covered.  The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
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 February 23, 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 response and treatment with no 
transport provided on February 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x32) and home 
health skilled nursing (G0299 x32). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any diagnosis/condition that would be expected to require an additional 32 
units of home health skilled physical therapy/skilled nursing for ongoing treatment thus the records do not 
show that 32 additional units home health physical therapy/skilled nursing would be required to effectively 
provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x32) and home health skilled nursing 
(G0299 x32).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met as the pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging corroboration of other plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).