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

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation mileage 
(A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation mileage. You say that you  
have been trying to obtain an ear nose and throat appointment since last year and all their specialists are more 
than 50 miles. The Plan denied your request. The Plan says the requested transportation in each direction has 
exceeded the mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan for additional non-
emergency transportation mileage for an appointment. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional non-emergency transportation mileage (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special service. 
 
You asked the Plan to pre-approve the special service. You say that you expected to get all informative catalogs 
automatically. You say you did not have clear information on how the OTC benefit worked. The Plan denied 
your request. The Plan says the OTC benefit allowance per quarter cannot be carried over to another quarter. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC drug allowance benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC drug benefit in excess of Medicare coverage, the OTC allowance per quarter 
cannot be carried over to another quarter, Therefore, we decided that the Plan does not have to pre-approve the 
special service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a visual field assessment (0379T) (ForseeHome Age-
Related Macular Degeneration monitoring program). 
 
You asked the Plan to pre-approve the ForseeHome Age-Related Macular Degeneration monitoring program. 
You say that the enrollee has macular degeneration, this prescription allows for daily tests that would inform 
you of changes in diopter immediately, and is needed to provide the enrollee with the care they require. The 
Plan denied your request. The Plan says this request as not reasonable and 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 ForseeHome Age-Related Macular 
Degeneration monitoring program. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case.  Our physician reviewer found the ForseeHome Age-Related 
Macular Degeneration monitoring program is considered investigational/experimental as additional clinical 
studies are needed to demonstrate that it affects visual outcomes. 
 
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 ForseeHome Age-Related Macular Degeneration monitoring program have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a visual field assessment 
(0379T) (ForseeHome Age-Related Macular Degeneration monitoring program).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057), implant supported retainer for ceramic FPD (D6075) and pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve dental services. You say that you believe the services should be covered. 
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. Implant supported retainer for 
ceramic FPD (D6075) is not covered under the Plans dental benefits. Custom fabricated abutment  includes 
placement (D6057) and pontic - porcelain/ceramic (D6245) are covered by your plan but not when to be used 
toward fabrication of a non-covered service. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6057 is not among 
those covered under this benefit. Custom fabricated abutment  includes placement (D6057) and pontic - 
porcelain/ceramic (D6245) are covered by your plan but not when to be used toward fabrication of a non-
covered service. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment 
 includes placement (D6057), implant supported retainer for ceramic FPD (D6075) and pontic - 
porcelain/ceramic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), -surgical placement 
of implant body (D6010), bone graft (D6104), guided tissue regeneration- nonresorbable barrier, per site 
(D4267), surgical access to an implant body (D6011), and custom fabrication abutment (D6057). 
 
You asked the Plan to pre-approve implants and associated services. 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 
guided tissue regeneration (D4266), -surgical placement of implant body (D6010), bone graft (D6104), guided tissue regeneration- nonresorbable barrier, per site (D4267), surgical access to an implant body (D6011), and 
custom fabrication abutment (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis reader.  
You asked the Plan to pre-approve the Dexcom G6 Mis reader. You say that the medical records support the 
need for the Dexcom G6 Mis reader. The Plan denied your request. The Plan says this enrollee does not have 
documentation of history of problematic hypoglycemia. 
 
The Plan follows 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 Dexcom G6 Mis reader. Our 
reviewer says that the Dexcom G6 Mis reader is not a medical necessity. Our physician reviewer found the 
enrollee is not using insulin and the record does not show of any low blood glucose sugar of class 2. 
 
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 Dexcom G6 Mis reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 Mis reader.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you have 
multiple appointments coming up with specialists. The Plan denied your request. The Plan says the evidence 
shows that you have used twenty-four (24) trips covered by the Plan for the year 2023. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional non-emergency routine transportation trips for upcoming appointments. Based on this information, 
we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation 
trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 therapeutic CGM. You say that the medical records 
submitted support the necessity for the CGM. The Plan denied your request. The Plan says the enrollee is not 
on insulin and there is no hypoglycemia. 
 
The Plan follows 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 FreeStyle Libre 2 therapeutic CGM. 
Our reviewer says that the CGM is not medically necessary. Our physician reviewer found the enrollee had low 
blood glucose sugar with Glipizide but is now off Glipizide which should stop the blood glucose sugar from 
going low. Since the low blood glucose sugars are not persistent at this point and the enrollee is not using 
insulin the criterial for CGM coverage are not 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 FreeStyle Libre 2 therapeutic CGM 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 
therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) provide 
on March 8, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that this should be covered 
in full. 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 a $30 
copayment for visits to an ophthalmologist or optometrist for Medicare-covered vision care.  
 
You have been asked to pay a $30 copayment for a medical eye examination. This item/service falls within the 
Medicare-covered vision care 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. Therefore, we decided that the Plan does not have to waive the copayment for a medical 
eye examination (92014) provide on March 8, 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 October 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell in 
the shower and your wife called the emergency medical device for assistance. You also say that the ambulance 
came and helped you get up because you could not get up on your own. 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 October 3, 2022. 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 October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment teeth #12, #13 (D6057), 
abutment supported porcelain/ceramic crown teeth #12, #13 (D6058),  
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have already been approved for 2 implants. 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutment teeth #12, #13 (D6057), abutment supported 
porcelain/ceramic crown teeth #12, #13 (D6058),
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 1, 2023, 
through January 4, 2023.  
 
You asked the Plan to pay for self-administered drugs. You say that you are not sure what is being denied. The 
Plan denied your request. The Plan says 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 self-administered drugs provided 
from January 1, 2023, through January 4, 2023.  
 
Benefits for self-administered drugs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI of the cervical spine. You say that you say that this is medically 
necessary for you to be diagnosed properly with the specialist you are going to see. The Plan denied your 
request. The Plan says there has been no contact with your provider after completing treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI of the cervical spine. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found the only medical record 
provided was a telemedicine visit to a hematology on March 17, 2023.  There is mention of continued neck 
pain and a need to have the MRI exam completed prior to visiting a specialist. There is no history of any 
neurological abnormality or even a history describing clinical features, plain x-rays or any conservative therapy 
rendered. The medical necessity of the requested MRI of the cervical spine has not been established in the 
records provided. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on March 6, 2023, 
through March 8, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the medication was given to you by the 
hospital, and they would not let you take your own medication. 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 pay for the self-administered drugs 
received on March 6, 2023, through March 8, 2023.  
 
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home oxygen concentrator device and small 
lightweight portable oxygen concentrator (POC) Inogen-pulse-dose.  
 
You asked the Plan to pre-approve a home oxygen concentrator device and small lightweight portable oxygen 
concentrator (POC) Inogen-pulse-dose. You say that the items are medically necessary. The Plan denied your 
request. The Plan says the medical information received with the request, does not indicate that the 
portable oxygen tanks provided to you are not meeting your needs for portable oxygen. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a stationary oxygen concentrator and portable oxygen tanks. This device 
serves the same purpose as a home oxygen concentrator device and small lightweight portable oxygen 
concentrator (POC) Inogen-pulse-dose. Therefore, we decided that the Plan does not have to pre-approve a 
home oxygen concentrator device and small lightweight portable oxygen concentrator (POC) Inogen-pulse-
dose.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service December 
10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the consult was coded correctly. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99203 is not supported. The case file shows that the 
enrollee received an evaluation and management services (99231) by a provider in the same group practice 
within the previous three years. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99203 billed for date of service December 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95822-26-XU billed for date of service December 9, 
2022.  
 
You asked the Plan to pay for code 95822-26-XU. You say that the medical records support payment. The Plan 
denied your request. The Plan says code 95822-26-XU is not supported by the medical record. The submitted 
records indicate that electroencephalogram (EEG) during intracranial surgery was performed. There is a more 
appropriate code that should be used in this circumstance. Please note- code 95937-26 has been approved by 
the Plan and is not at issue. 
 
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 95822-26-XU is electroencephalogram (EEG); recording 
in coma or sleep only.  
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 code 95822-26-XU. Our reviewer says that code 95822-26-
XU is not supported by the medical record. Our reviewer found the procedure report describes neuromonitoring 
services provided for anterior cervical discectomy and fusion C4 - C7 procedure.  Code 95822, 
Electroencephalogram or EEG, is a diagnostic test that uses small electrodes attached to the scalp to measure 
the electrical activity of the brain. In this procedure the provider performs the EEG when the patient is in a state 
of coma or sleep. There is a more appropriate code to report for service provided.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95822-26-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 95822-26-XU billed for date of service December 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on December 20, 2022, 
through December 26, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary 
for you as oral medications were not treating your condition. 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 pay for the self-administered drugs 
received on December 20, 2022, through December 26, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.