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

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee is experiencing a lot of pain and 
would benefit from the requested orthotics.  The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and you would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided on June 23, 2023. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the items rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided on 
June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on June 29, 2023. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you are requesting 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 the outpatient clinic visit 
provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 an office visit provided 
on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that your previous dentures do not fit properly 
and that it is medically necessary for you to get a new denture to eat and speak clearly. 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 April 4, 2023. Therefore, 
we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a bath/shower chair. You say that you cannot use the bathroom or take a 
shower without assistance and the proper shower commode chair due to your paraplegic condition. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not have a condition which requires 
a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 21, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and you would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-precision abutment (D6191) on teeth #22 and 
#27, the custom abutments (D6057) on teeth #22 and #27, and the implant placements (D6010) on teeth #22 
and #27. 
 
You asked the Plan to pre-approve the dental services. You say that your dentures are moving, and your dentist 
is recommending these services in order to attach the dentures to your gums. The Plan denied your request. The 
Plan says the services are not a covered benefit. 
 
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 dental services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the semi-precision 
abutment (D6191) on teeth #22 and #27, the custom abutments (D6057) on teeth #22 and #27, and the implant 
placements (D6010) on teeth #22 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on July 18, 2023.  
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the 
related supply allowance provided by an out-of-network provider on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 29, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says you are not enrolled 
in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain or ceramic crown (D2740) for teeth 7, 8, and 
11, gingivectomy (D4212) for teeth 6, 7, and 11, and core buildup (D2950) for teeth 6, 7, and 11. 
 
You asked the Plan to pre-approve the dental services. You say that you need extensive dental work. You also 
say your dentist submitted a treatment plan to which the Plan responded stating they would cover one crown. 
You also say you do not feel that is satisfactory. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. The Plan also says gingivectomy and core buildup 
(D2950) are not covered under this benefit.  
 
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 porcelain or ceramic crown (D2740) was exhausted on date of service with the previous 
appealed predetermination. However, you may wish to submit a new request for coverage under your 2024 
benefits. Gingivectomy and core buildup (D2950) are excluded from this benefit.  Therefore, we decided that 
the Plan does not have to pre-approve porcelain or ceramic crown (D2740) for teeth 7, 8, and 11, gingivectomy 
(D4212) for teeth 6, 7, and 11, and core buildup (D2950) for teeth 6, 7, and 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 3, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on August 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on August 29, 2023, billed with 13 units 
of code 87798. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment for the panel testing at issue have not been 
met. 
 
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. Specifically, the Plan has not provided a copy of the claim to document that 
greater than 1 unit of code 87798 was billed for the services at issue. It is the Plan's responsibility to support its 
denial with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for laboratory services provided on August 29, 2023, billed with 13 units of 
code 87798.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS System. 
 
You asked the Plan to pre-approve the SPRINT PNS System. You say that the SPRINT PNS System is 
medically necessary. The Plan denied your request. The Plan says the SPRINT PNS System 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 System. Our reviewer 
says that the requested SPRINT PNS System is not considered medically reasonable and necessary. Our 
physician reviewer found that the SPRINT PNS System experimental for chronic pain treatment. More research 
is needed on 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 SPRINT PNS System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 5, 2023.  
 
You asked the Plan to pay for procedure code 99232. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 
99223-AI. 
 
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 code 99232 
is a column two code to column one code 99223-AI with a modifier indicator of 0. The column two code is therefore not payable. 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 code 99232 billed for date of service June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751). 
 
You asked the Plan to pre-approve a retainer crown. You say that you want this approved so your dentist can 
put on the crown and other services as needed. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 a 
retainer crown (D6751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor and supplies to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the continuous glucose monitor and supplies. You say that this is supported 
in the records. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor and supplies 
to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5226). 
 
You asked the Plan to pre-approve this 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 dental item requested in this 
case 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 October 31, 2023. Specifically, the 
Plans contract states that one lower partial denture is covered every 60 months.  
  
 
You previously received this dental item on October 31, 2023, less than 60 months prior, which was paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for the dental item requested in this case. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 You asked the Plan to pre-approve the additional miles. The Plan denied your request. The Plan says the 
service is a covered benefit, but the request will exceed the benefit limits set in the agreement for routine 
transportation 
 
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 75 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 82 miles. 
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 routine 
transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 You asked the Plan to pre-approve the additional miles. You say that you are homebound and need to be 
transported to an appointment at a medical center. The Plan denied your request. The Plan says the service is a 
covered benefit, but the request will exceed the benefit 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 50 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 63 miles for a 
medical 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 routine transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5211). 
 
You asked the Plan to pre-approve the upper partial denture (D5211). You say that you understood that you 
were paying for vision and dental needs. You say you do not understand why this is not covered because it is a 
dental need. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 upper partial denture (D5211) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the upper partial denture (D5211).