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

 
We decided that the Plan does not have to pay for the core buildup (D2950), pontics (D6245), retainer crowns 
(D6740), the bone replacement graft (D7953), and an unspecified oral surgery procedure (D7999) for tooth 
#11, #12, #13, and #14 provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had a broken bridge, and the dental 
procedures were necessary, and the provider told you the Plan would cover some of the cost. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the core buildup, 
pontics, retainer crowns, the bone replacement graft, and an unspecified oral surgery 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 pay for the core 
buildup (D2950), pontics (D6245), retainer crowns (D6740), the bone replacement graft (D7953), and an 
unspecified oral surgery procedure (D7999) for tooth #11, #12, #13, and #14 provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2752), the post and core (D2952), and the 
endodontic therapy (D3320) for tooth #20 provided by an out-of-network provider on January 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you paid for the procedures and would like to be 
reimbursed for some of the cost. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
  The record shows you received the requested 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 pay for a crown (D2752), the post and core (D2952), and the endodontic therapy (D3320) for tooth #20 
provided by an out-of-network provider on January 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on December 29, 
2021. 
 
You asked the Plan to pay for the PT services. You say that you are unsure why all the claims were denied and 
ask for the claims to be reprocessed. The Plan denied your request. The Plan says the claim was not received in 
one calendar year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a claim for the PT services was not filed until February 2, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the physical therapy services provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung 
cancer screening provided on April 13, 2023. 
 
You asked the Plan to pay for the requested LDCT scan. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollee had an LDCT performed within the last 12 months 
and that claim was paid correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that 12 months have not passed since the enrollee's last 
LDCT performed on January 11, 2023. Therefore, we decided that the Plan does not have to pay for a low dose 
computed tomography (LDCT) scan for lung cancer screening provided on April 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs provided on March 28, 
2023. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that you feel you should be reimbursed 
for the charges. 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 pre-approve the self-administered drugs 
provided on March 28, 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 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
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 a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets LTACH 
criteria based on Medicare guidelines and would have already admitted if a straight Medicare product was 
chosen. The Plan denied your request. The Plan says the enrollee's records do not show the above criteria of 
medical necessity. When ready to leave the hospital, services can safely be received in another setting. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee does not meet this 
requirement, medical necessity cannot be established 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford the amount due because you 
are on a limited income. 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 $442 on date of service January 19, 2023, and $558 on date of service April 10, 2023 
($442 + $558 = $1,000). After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay for dental services provided on April 
10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (D9944) 
provided on April 21, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that you have implants which are necessary because 
you grit and grind and loosen your teeth. You also say that the night guard prevents you from damaging the 
implants and the teeth you have left. The Plan denied your request. The Plan says this service is not covered 
under the benefit package.  
 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  service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an occlusal guard 
 hard appliance, full arch (D9944) provided on April 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a normal saline solution infusion. 
 
You asked the Plan to pre-approve a normal saline solution infusion. You say that the enrollee needs 
phlebotomy due to polycythemia reactive. The Plan denied your request. The Plan says a normal saline solution 
infusion 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 a normal saline solution infusion. Our 
reviewer says that a normal saline solution infusion is not medically necessary. Our physician reviewer found 
that you had phlebotomy and received an infusion of normal saline. However, there are not records to explain 
the rational for this practice or why you require phlebotomy with a hematocrit of 43. Therefore, the service is 
not reasonable or medically 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 a normal saline solution infusion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a normal saline solution infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 21, 2022, billed with 
procedure code 99454. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99454 is remote monitoring of physiologic parameter(s) 
(eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily 
recording(s) or programmed alert(s) transmission, each 30 days. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical record includes a signed 
physician order " blood pressure (BP) Monitor", dated "10/30/2018", and blood pressure and pulse monitoring 
for dates of service April 21, 2022, through May 20, 2022. The physician order submitted is dated 2018, which 
is inconsistent with dates of service, procedure performed, as well as no procedures were provided on date of 
service billed.  In this case, there is insufficient documentation to verify 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 the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 21, 2022, billed with procedure code 
99454.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you say you do not agree with the denial of 
payment for services you received. 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. This benefit includes the 
requested D0150 and D0210, but each is limited to one procedure every three plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered comprehensive oral evaluation - new or established patient (D0150) and intraoral 
- complete series of radiographic images (D0210) on date of service August 14, 2020. Therefore, these benefits 
have been exhausted as of April 17, 2023. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) provided on April 17, 023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64624). 
 
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. 
 
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 of genicular nerve blocks and radiofrequency 
ablation for pain after total knee arthroplasty. It 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 (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. 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 June 6, 2023. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is necessary because 
you are in need of therapy services to maximize the potential to return to your home setting. The Plan denied 
your request. The Plan says admission to a SNF if not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown-porcelain fused to high noble metal for 
tooth number 6 (D6750) and pontics-porcelain fused to high noble metal for teeth number 7, 8, 9 (D6240 x 3). 
 
You asked the Plan to pre-approve the dental items. 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 items 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 items was previously exhausted. Specifically, the Plans contract states 
that up to four units of fixed dentures are covered per year. The Plan previously approved retainer crowns for 
teeth number 10, 11, and 13 and a pontic for tooth number 12. Therefore, you have exhausted the allowable 
benefit for the requested dental items in this case. Therefore, we decided that the Plan does not have to pre-
approve a retainer crown-porcelain fused to high noble metal for tooth number 6 (D6750) and pontics-porcelain 
fused to high noble metal for teeth number 7, 8, 9 (D6240 x 3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the criteria for approval have 
not been met. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient rehabilitation facility (IRF) stay to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an IRF stay with an OON provider. You say that you are appealing because 
you do not want to go to the in-network facility. You also say that the in-network facility did not call back 
when the social worker reached out for availability for you to be there. The Plan denied your request. The Plan 
says the medically necessary services are available in the service area with participating providers. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
an inpatient rehabilitation facility (IRF) stay to be provided by an out-of-network (OON) provider.