Persius/hicric huggingface dataset:
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 the CGM. You say that the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not 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. Specifically, the request for authorization 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the imaging should be approved 
based on medical necessity until the age of 80. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 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 the enrollee's age is not between 50-77. Therefore, 
we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5110, D5120) 
provided on August 10, 2022. 
 
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 April 28, 2021. 
Therefore, we decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5110, 
D5120) provided on August 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 29, 2022 to August 
27, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for home health services the location where 
services were provided must always be reported along with the first visit reported on the claim. 
 
We looked at the file and Medicare rules. The claim did not include a required "Q" code to note the location where the service was provided. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided on July 29, 2022 to August 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on May 17, 2022. 
 You asked the Plan to pay for the eye exam. You say that you were not notified of the enrollee's hospice status. 
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 an eye exam provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction for teeth #22, #23, #24, #25, #26, #27, 
#70 (D7140) provided on March 31, 2023. 
 
You asked the Plan to pay more 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 March 31, 2023. 
Therefore, we decided that the Plan does not have to pay more for an extraction for teeth #22, #23, #24, #25, 
#26, #27, #70 (D7140) provided on March 31, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for home health care and PT services provided 
from January 5, 2023, to January 7, 2023. 
 
You asked the Plan to waive the deductible for home health care and PT services. You say that your physical 
therapy appointments are supposed to be covered by the Plan. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $400 deductible which applies to home health care and PT services.  
 
The item or service you asked the Plan to waive the deductible for falls within the home health care and PT 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $400 deductible which applies to home health care and PT services. This cost sharing is a contractual 
obligation that had not been met at the time home health care and PT services was received on January 5, 2023, 
to January 7, 2023. Therefore, we decided that the Plan does not have to waive the deductible for home health 
care and PT services provided from January 5, 2023, to January 7, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 17000, 99336 rendered on August 14, 
2023. You asked the Plan to pay for the procedure codes 17000, 99336. You say that the services rendered were not 
related to the enrollee' hospice condition. 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 the procedure codes 17000, 99336 rendered on August 14, 
2023.
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 these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit.  
 
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 these items may be appropriate, they do 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3310) for tooth #26 and to 
pay for the intraoral radiographic images (D0220 and D0230) and the endodontic therapy (D3310) for tooth 
#10 provided on April 3, 2023, and March 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 $206 for dental services on January 12, 2023. On January 24, 2023, the Plan paid $1,155 
for dental services. On February 16, 2023, the Plan paid $234 for dental services. On March 8, 2023, the Plan 
paid $761 for dental services. On April 3, 2023, the Plan paid $644 for dental services. For the year of 2023 the 
Plan paid $3,000 ($206 paid + $1,155 paid + $234 paid + $761 paid + $644 paid) for dental services; therefore, 
your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of April 3, 
2023. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy (D3310) for 
tooth #26 and to pay for the intraoral radiographic images (D0220 and D0230) and the endodontic therapy 
(D3310) for tooth #10 provided on April 3, 2023, and March 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on March 1, 2023, 
through March 9, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
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 1, 2023, through March 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #7, #8, #9, #10, #23, #24, 
#25, and #26 and retainer crowns (D6740) for tooth #6, #11, #22, and #27. 
 
You asked the Plan to pre-approve the dental services. You say that you have decay and bone loss, and you are 
unable to eat or chew anything. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because pontics and retainer crowns 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 
pontics (D6245) for tooth #7, #8, #9, #10, #23, #24, #25, and #26 and retainer crowns (D6740) for tooth #6, 
#11, #22, and #27.
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 CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM.  
 
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 a CGM. Our reviewer says that the 
enrollee does not meet criteria for the requested CGM.  Our physician reviewer found criteria for CGM use 
require insulin use or low blood glucose events. Neither apply here and there is no reason given why the 
enrollee cannot use a glucometer for his needs. Pioglitazone usually does not cause low blood glucose levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of a lower extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that the imaging is requested due to the enrollee's cancer 
history. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has a history of prostate cancer 
metastatic to bone and pelvic lymph nodes. His PSA is 147. He has a history of a positive pelvic MRI in the 
past. His left hip/leg weakness is a red flag especially given his history of known prostate metastatic disease, 
and the requested MRI of the left hip and lumbar spine should be approved. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of a lower extremity joint.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of dental implants (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that it is difficult to eat food without getting a 
migraine and you need the dental implants. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because dental implants 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 
surgical placement of dental implants (D6010).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 17, 2023. 
 
You asked the Plan to waive the copayment for an MRI. You say that you think a $250 copayment is too high 
and would like it to be waived. 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 $250 
copayment for diagnostic radiology services.  
 
 
  You have been asked to pay a $250 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests 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 an MRI provided on March 
17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown for teeth #3, #4, and #20 (D6750) and a 
pontic for teeth #5 and #19 (D6240). 
 
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 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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown for teeth #3, #4, and #20 (D6750) and a pontic for teeth #5 and #19 
(D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you got a second opinion, and this should be a 
covered benefit. 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 January 31, 2023, and 
March 31, 2023. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010 x 3). 
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested dental 
items/services 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 requested items/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implants (D6010 x 3).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve penile prosthesis placement (54401, 54405). 
 
You asked the Plan to pre-approve penile prosthesis placement. You say that you want the Plan to approve the 
services. The Plan denied your request. The Plan says the requested services are 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 penile prosthesis placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found placement of a penile implant is considered an acceptable 3rd line 
treatment for men with severe erectile dysfunction. In this case, first line treatment with Cialis has been 
effective. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of penile prosthesis placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve penile prosthesis placement (54401, 54405).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).