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

 
We decided that the Plan does not have to pre-approve the prefabricated abutments (D6056 x 4) on tooth #s 5, 
21, 19, 20, the abutment supported porcelain/ceramic crowns (D6058 x 4) on tooth #s 5, 21, 19, 20, the surgical 
placements of implant bodies (D6010 x 2) on tooth #s 19, 20, and the sinus augmentation (D7952). 
 
You asked the Plan to pre-approve the dental services. You say that you are trying to finish the dental work that 
was started in 2022.  You say you have two unfinished implants in your gums. 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 Plan's 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 when the Plan previously approved D6056 
and D6058 on tooth #3. Also, the Plan approved D6056 and D6058 on tooth #4. The Plan approved D6010 on 
tooth #s 4 and 5. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the sinus augmentation (D7952) is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
prefabricated abutments (D6056 x 4) on tooth #s 5, 21, 19, 20, the abutment supported porcelain/ceramic 
crowns (D6058 x 4) on tooth #s 5, 21, 19, 20, the surgical placements of implant bodies (D6010 x 2) on tooth 
#s 19, 20, and the sinus augmentation (D7952).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided March 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that please find appeal information that 
describes the medical necessity of the PrismRA test to inform consideration of payment. The Plan denied your 
request. The Plan says that PrismRA has not been cleared or approved by the FDA. 
 
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. This test is not FDA (Food and Drug Administration) approved and 
search of the DEX Diagnostic Exchange registry for the diagnostic program MolDX Technical Assessment, 
states that this PrismRA test is not covered. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the PrismRA testing (81479) provided March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary/mandibular partial dentures (D5214, D5213). 
 
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 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 pre-approve 
maxillary/mandibular partial dentures (D5214, D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for x-rays on February 10, 2023.  
 
You asked the Plan to waive the deductible for x-rays. You say that you did not want or need the x-rays, the 
doctor wanted this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time x-rays was received on February 10, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for x-rays on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring in a nursing home provided 
on March 31, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring in a nursing home. You say that this was 
medically necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote physiologic 
monitoring in a nursing home provided on March 31, 2023.
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 has left hip pain. The Plan denied your 
request. The Plan says the enrollee rehab needs are not complex enough for an IRF. 
 
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 
was admitted for hip replacement surgery. Medical problems are stable, and there are no complex nursing or 
rehabilitation needs.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, 
each joint (separate procedure) rendered on December 2, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 28270 is "Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate 
procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite a 15 blade 
was used to perform a capsulotomy along the dorsal aspect of the right 1st MPJ and proximal phalanx. The 
periosteum and capsule were reflected to expose the 1st metatarsal head as well as the proximal phalanx. 
Utilizing a sagittal saw, the dorsal spurring along the head of the 1st metatarsal as well as the base of the 
proximal phalanx were resected. Then a transverse capsulotomy was performed of the 2nd metatarsophalangeal 
joint following release of the medial collateral ligament. Therefore, the records do support that CPT 28270: 
capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) was 
rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) rendered 
on December 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve the injection. You say that that you have chronic wrist pain due to kienbock 
disease and wrist osterarthiristis. The Plan denied your request. The Plan says that a platelet rich plasma 
injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
platelet rich plasma injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core and crown for tooth #19 
(D2954, D2740) provided on March 23, 2023, to April 7, 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 a 
prefabricated post and core and crown for tooth #19 (D2954, D2740) provided on March 23, 2023, to April 7, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 system. 
 
You asked the Plan to pre-approve a Dexcom G7 system. You say that the Dexcom G7 is vital to your health. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 Dexcom G7 system. Our reviewer 
says that the coverage criteria has been met. Our physician reviewer found that you have had low blood glucose 
events and the CGM has helped to prevent these events while driving. The records show you are on 
glimepiride, which can cause low blood glucose levels. 
 
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 Dexcom G7 system have been met. Therefore, we decided that the Plan has to 
pre-approve a Dexcom G7 system.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on April 05, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on April 05, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for intravenous (IV) infusion therapy 
provided on January 11, 2023, to April 19, 2023. 
 
You asked the Plan to reduce the coinsurance for intravenous (IV) infusion therapy. You say that you are 
unhappy with the cost share applied because the amounts are not the same for every visit. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for intravenous (IV) infusion therapy. This item/service falls 
within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The total you owe is $106.48, which is 20% of the allowed 
amount for the IV infusion therapy ($532.40 allowed x 20% = $106.48). Therefore, we decided that the Plan 
does not have to reduce the coinsurance for intravenous (IV) infusion therapy provided on January 11, 2023, to 
April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraoral radiographic images (D0220) and a 
cleaning (D1110) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that there are no in-network providers available 
that have opening appointments within a couple months. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. Also, there are 
multiple in-network providers available in your service area. 
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the 
intraoral radiographic images (D0220) and a cleaning (D1110) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245 x 2) and retainer crowns (D6740 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because your 
previous providers office is permanently closed. 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 were exhausted on date of service June 30, 2021, and 
authorization A0230607154568. Therefore, we decided that the Plan does not have to pre-approve pontics 
(D6245 x 2) and retainer crowns (D6740 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix Glucose test strips. 
 
You asked the Plan to pre-approve True Metrix Glucose test strips. You say that you would like approval for 
these diabetic supplies. 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 True Metrix Glucose test strips. Therefore, we decided that the Plan does not have to pre-approve True 
Metrix Glucose test strips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on September 10, 2022.  
You asked the Plan to pay for the air ambulance transport and air mileage. You say that this transport meets 
medical necessity guidelines  The Plan denied your request. The Plan says the information submitted does not 
support this level of service.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport and air mileage. 
Our reviewer says that the air ambulance transport was not medically necessary. Our physician reviewer found 
the use of an air ambulance, rather than a ground ambulance, is not shown to have been medically necessary. It 
is not shown that multiple, closer facilities, were unable to care for or accommodate 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 air ambulance transport and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one way 
and air mileage provided on September 10, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95800 and 95819 provided on January 22, 2023. 
 
You asked the Plan to pay for procedure codes 95800 and 95819. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the records do not support 
the services billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied payment for procedure codes 95800 and 95819 due 
to the date of service on the claim submitted not matching the date of service on the medical records provided. 
However, the file shows that the provider submitted medical records with the correct January 22, 2023, date of 
service. The Plan provided no other rationale for their denial. Therefore, we decided that the Plan has to pay for 
procedure codes 95800 and 95819 provided on January 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown for tooth number 8 
(D2740). 
 
You asked the Plan to pre-approve the dental item. 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 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 item was exhausted on date of service February 4, 2022. Specifically, the 
Plans contract states that one porcelain/ceramic crown is covered every 60 months.   
 
 
 
You previously received this item on February 4, 2022, less than 60 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the requested dental item in this case. Therefore, 
we decided that the Plan does not have to pre-approve a porcelain/ceramic dental crown for tooth number 8 
(D2740).