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

 
We decided that the Plan does not have to pay for the evaluation of neuropsychological test services provided 
on April 26, 2023. 
 You asked the Plan to pay for the evaluation of neuropsychological test services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the evaluation of neuropsychological test services provided 
on April 26, 2023.
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), panoramic radiographic image (D0330), and bitewing - 
single radiographic image (D0270) provided on March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that the insurance would cover 
the payment. You also say that it is hard to come-up with the copayment as you and your wife live on social 
security. The Plan denied your request. The Plan says your benefit for the requested services $1,500 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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $1,500 towards the cost of dental services provided in 2023. 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), panoramic radiographic image (D0330), and bitewing - single radiographic image 
(D0270) provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6539 that 
were issued on June 21, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you have a prescription for the 
stockings, and they were necessary because they would benefit you from the procedures that were done. The 
Plan denied your request. The Plan says this item is not covered by Medicare also the provider is a non-
Medicare certified provider. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6539 that were issued on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on August 30, 
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 $3,500 annual maximum 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 $3,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for limited oral evaluation (D0140) provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), and bone replacement graft for ridge preservation - per 
site (D7953) provided on July 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were experiencing pain in your teeth and 
decided to attend your dentist to determine the cause, who then referred you to another provider. You also say 
that during the consultation it was determined that your tooth was loose with an infection so you consulted to 
having the procedures carried out. The Plan denied your request. The Plan says these services are not covered 
under your plan. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue 
regeneration - resorbable barrier, per site (D4266), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and bone replacement 
graft for ridge preservation - per site (D7953) provided on July 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 13, 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 $4,000 annual maximum 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 $4,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 20, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that an unknown service or provision was 
denied for $30.93. You say that this is an addition to the $110.00 expected as a co-pay for this emergency room 
visit. The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part 
B coverage. 
 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 pay for the self-administered drugs 
provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames (V2020), lenses (V2103), polycarbonate lenses (V2784), and 
anti-reflective coating (V2750) provided on May 25, 2023. 
 
You asked the Plan to pay for frames (V2020), lenses (V2103), polycarbonate lenses (V2784), and anti-
reflective coating (V2750). You say that the provider is charging you an additional $22.30 for the services they 
provided on that day. You also say you made it clear that you do not want to be charged for anything that your 
insurance will not cover. The Plan denied your request. The Plan says that the total amount billed for your 
eyewear on the claim is $428, leaving you with a balance of $28. The Plan also says there was a 20% reduction 
on the remaining $28 balance leaving you with a responsibility of $22.40. 
 
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 up to $400 per year for eyeglasses and lenses. 
 
We looked at the file and the Plan's rules. The Plan rules says that the Plan pays up to $400 per year for 
eyeglasses and lenses. The record does not show this benefit was exhausted with this date of service. 
Specifically, the EOC states that the Plan pays $400 toward the eyeglasses. The record shows on the Medical 
and Hospital Claims processed in May 2023 that the Plan paid $290. Therefore, the benefit has not been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), lenses 
(V2103), polycarbonate lenses (V2784), and anti-reflective coating (V2750) have been met. Therefore, we 
decided that the Plan has to pay for frames (V2020), lenses (V2103), polycarbonate lenses (V2784), and anti-
reflective coating (V2750) provided on May 25, 2023.  
 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  the acupuncture services, manual therapy techniques and the 
office visits provided on January 13, 2023, to, March 13, 2023. 
 
You asked the Plan to pay for  the acupuncture services, manual therapy techniques and the office visit. You 
say that you are requesting that the five appointments be kept as a deduction in the total allotted acupuncture 
visits. The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have been diagnosed with unspecified fracture of 
shaft of right fibula, initial encounter for closed fracture (lower leg), and acupuncture is only covered for 
chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services, 
manual therapy techniques, and the office visits provided on January 13, 2023, to, March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for pain. More research is needed. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dog training services. 
 
You asked the Plan to pre-approve dog training services. You say that you need to learn the mechanics of 
training which a trainer can do faster and better than you can on your own. The Plan denied your request. The 
Plan says this service is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, 
a provider must be enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not eligible for 
coverage. Based on this information, we decided that Medicare rules for coverage of dog training services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve dog training services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ device (0775T). 
 
You asked the Plan to pre-approve the LinQ device. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LinQ device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. There is no clear history of sacroiliac (SI) joint pain onset or failure of conservative 
treatment directed to the SI joint. Multiple other plausible pain generators including at the lumbosacral spine 
are evident. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented, or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 LinQ device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LinQ device (0775T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the CardioMEMS device is considered unproven and is not medically necessary. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management.  Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the NALU peripheral nerve stimulator (PNS) (64555, 
64590). 
 
You asked the Plan to pre-approve the NALU peripheral nerve stimulator. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the NALU peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found NALU PNS stimulator is experimental for chronic pain. More research 
is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the NALU peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the NALU peripheral nerve stimulator (PNS) (64555, 
64590).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that you are being referred and 
recommended to receive procedure for beneficial help with daily pain and better quality of life. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve block is experimental for knee 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on June 20, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you have always worked 
with this specific provider that is not in network and have always been reimbursed. The Plan denied your 
request. The Plan says that chiropractic manipulative treatment is available in network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 chiropractic manipulative treatment provided 
on June 20, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle test strips. 
 
You asked the Plan to pre-approve the FreeStyle test strips. You say that the enrollee struggles with the 
formulary strips due to being so small and due to arthritis. 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 FreeStyle test strips. Therefore, we decided that the Plan does not have to pre-approve FreeStyle test 
strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular partial denture (D5213, 
D5214). 
 
You asked the Plan to pre-approve 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 March 5, 2019. 
Therefore, we decided that the Plan does not have to pre-approve maxillary and mandibular partial denture 
(D5213, D5214).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299). 
 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 this is 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 the enrollee is 
noted to be medically stable. The enrollee does not require wound care, catheterization, tube feeding, or 
administration of intravenous or complex medications. The enrollee has been educated regarding their 
medications and they have not recently been hospitalized. The enrollee is modified independent with mobility 
and may require some degree of assistance, but this does not require skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299).