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

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that it should be your providers responsibility to 
check if your benefits are exhausted. 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 August 17, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 
16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on June 23, 
2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your supplemental 
dental policy.  
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene 
instructions (D1330) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on April 4, 
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 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 November 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on 
April 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 provided on January 31, 2023. 
 
You asked the Plan to pay for procedure code G0416. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
G0416. 
 
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 G0416 is Surgical pathology, gross and microscopic 
examinations, for prostate needle biopsy, any method. 
 
We find that CPT code G0416 is not supported in the medical record. Specifically, the records only support the 
surgical pathology, gross examination and not the microscopic examination. Based on this information, we decided that Medicare rules for coverage of procedure code G0416 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code G0416 provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement or re-bond of a crown (D2920) for tooth #2 
provided on December 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were not told that the procedure would not 
be covered by the Plan, and you would of went somewhere else that was cheaper. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the recement or re-bond of a 
crown is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
recement or re-bond of a crown (D2920) for tooth #2 provided on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 day sensor. The Plan denied your request. The Plan 
says the medical records submitted do not establish that the Freestyle Libre 2 CGM sensor is reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 14 day sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency transportation. 
 
You asked the Plan to pre-approve the non-emergency transportation. You say that you cannot drive and really 
need the transportation. The Plan denied your request. The Plan says the request exceeds the limit of the 
supplemental benefit and does not meet criteria. 
 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. 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 the non-emergency transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs, self-administered. 
 
You asked the Plan to pay for the drugs, self-administered. 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 drugs, self-administered.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is needed to evaluate for mass due to 
abnormal weight loss. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there are no pulmonary complaints or recent 
chest x-rays in the records. The medical necessity of the requested CT of the chest has not been established in 
the submitted records. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7240) for tooth #1 and 
#32 and an unspecified adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain, and you have an infection 
in your gum and the treatment needs to be done as soon as possible. The Plan denied your request. The Plan 
says the denial of authorization for these services is correct, because the removal of impacted tooth and an 
unspecified adjunctive procedure are not covered by the 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of impacted tooth (D7240) for tooth #1 and #32 and an unspecified adjunctive procedure (D9999).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 30, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not in hospice at the time 
of transport. 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 ambulance services provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that your previous denture was stolen, and you 
need a replacement. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a partial upper denture (D5213) on December 9, 2019; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 9, 2019. Therefore, we decided 
that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5226). 
 
You asked the Plan to pre-approve the dental service. You say that you have no teeth left in the area where the 
partial is supposed to connect with, so you need a replacement denture. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a partial lower denture (D5214) on March 12, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 14, 2022. Therefore, we decided that 
the Plan does not have to pre-approve a partial lower denture (D5226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is being 
requested for ongoing management of acute care needs which require daily physician monitoring and 
interventions. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary and cannot approved until efficacy of this 
procedure has been established. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is an ongoing clinical trial studying the use of genicular blocks and radio 
frequency ablation in post-operative knee arthroplasty patients. This procedure is considered experimental at 
this time.  
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the item is medically 
necessary. The Plan denied your request. The Plan says theres no mention from the provider that the member 
had trunk or abdomen swelling. Moreover, there is no documentation that the member failed a four-week trial 
of the basic leg pump device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen or had at least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a 
technician who is skilled in and who regularly and successfully uses the appliance provided.  Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided on October 6, 2022. 
 
You asked the Plan to pay for the Infrared light therapy. The Plan denied your request. The Plan says Infrared 
light therapy is not considered medically necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile saline (A4216) purchased on November 14, 2022. 
 
You asked the Plan to pay for the sterile saline. You say that the item should be covered. The Plan denied your 
request. The Plan says the requested item, which was used to clean a wound caused by a trauma which did not 
require surgical closure or debridement, is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sterile saline have not been met. Therefore, we decided that the Plan does not have to pay for 
the sterile saline (A4216) purchased on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
The records provided do not include laboratory results. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the selective catheter placement, arterial system (35245, 
36247). 
 
You asked the Plan to pre-approve the outpatient services. You say that you have peripheral arterial disease 
(PAD). You say that it is causing the plugged arteries in your left leg. You also say that your trouble is getting 
progressively worse. The Plan denied your request. The Plan says the records do not support that you have 
functional impairment. The Plan also says that there is no evidence of conservative efforts to treat your 
symptoms. 
 
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 outpatient services. Our reviewer 
says that the requested outpatient services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a history of leg cramps in the setting of 
known atherosclerotic coronary disease. The record provided includes an arterial duplex report that shows 
multiphasic waveforms and no evidence of clinically significant obstruction. The record does not indicate a 
trial and failure of conservative treatment. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the 
requested outpatient services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the selective catheter placement, arterial system (35245, 36247).