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

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), the 
intraoral radiographic image (D0220), bitewings (D0274), the panoramic radiographic image (D0330), the 
application of fluoride (D1206), the resin-based composites (D2330, D2331, D2335, D2391, and D2392) for 
tooth #2, #3, #9, #10, #13, #15 #18, and #20, and the periodontal scaling and root planing (D4341) on all 4 
quadrants provided by an out-of-network provider on January 5, 2023, to January 9, 2023. 
 You asked the Plan to pay more for the dental services. You say that you could not find an in-network provider, 
so you went to the closest dentist office. 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 $1,000 for dental services on January 5, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 5, 2023. Therefore, we decided that 
the Plan does not have to pay more for the comprehensive oral evaluation (D0150), the intraoral radiographic 
image (D0220), bitewings (D0274), the panoramic radiographic image (D0330), the application of fluoride 
(D1206), the resin-based composites (D2330, D2331, D2335, D2391, and D2392) for tooth #2, #3, #9, #10, 
#13, #15 #18, and #20, and the periodontal scaling and root planing (D4341) on all 4 quadrants provided by an 
out-of-network provider on January 5, 2023, to January 9, 2023.  
 
Your complaint about the poor service from the out-of-network provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from April 1, 
2023, to April 30, 2023, by a Medicare opt-out provider. 
 
You asked the Plan to pay for the SNF services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
rendered by a provider who does not work with Medicare. 
 
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 requested provider in this case is not a network provider with the Plan nor do they participate with 
Medicare. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the 
Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) services provided from April 1, 2023, to April 30, 2023, by a Medicare opt-out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 13, 2023. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like reconsideration because 
the requested items are medically necessary. 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 for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 17, 2022, to 
November 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim should be paid as is because documentation supports code A41.9. The Plan denied your request. The Plan 
says that documentation does not support code A41.9 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9, defined as sepsis, unspecified organism. 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 pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that code A41.9 is supported in the documentation. Our physician reviewer 
found the enrollee had systemic inflammatory response syndrome with bacteriuria, so the enrollee meets 
criteria for sepsis from urinary tract infection, and thus diagnosis code A41.9 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on November 17, 2022, to November 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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 pay for procedure codes 23020 and 23430 rendered on March 22, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 23020: 
 
Capsular contracture release (eg, Sever type procedure) 
 
CPT 23430: 
 
Tenodesis of long tendon of biceps 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support CPT 
23020 or CPT 23430 as separate and distinct procedures from CPT 23472. 
 
In terms of CPT 23020, the procedure details cite there were arthritic changes of the glenoid and significant 
capsular contractures. Circumferential labral excision was completed with Bovie. Extensive capsular releases 
were also completed.However, the releases were performed to be able to prepare the joint for the total reverse 
shoulder replacement to be completed. 
 
In terms of CPT 23430, the procedure details cite biceps was torn in the groove. The biceps was sub-pectorally 
tenodesed with #2 FiberWire. The remaining tendon was excised through the interval proximally. However, 
this tenodesis was performed to allow for exposure and for the implants' placement. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 23020 and 23430 rendered on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scans of the thorax and abdomen 
and pelvis provided on March 31, 2023. 
 
You asked the Plan to pay for the CT scans. You say that the enrollee has an elevated cancer risk. 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 pay for the CT scans. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found CT of the chest (with contrast), abdomen 
and pelvis (with and without pelvis) done on March 31, 2023, showed no evidence for adenopathy or other 
neoplasm or malignant appearing process in the chest, abdomen, pelvis. There was no clinical rationale for the 
requested CT scans. 
 
 
  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 scans have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography (CT) scans of the thorax and abdomen and pelvis provided on March 31, 
2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. 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 MRI is imaging modality of choice for 
intraductal papillary mucinous neoplasm (IPMN) due to higher contrast resolution, particularly to examine the 
internal septation that is being described here on computed tomography (CT) scan. 
 
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 the abdomen.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
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 the enrollee did not have any symptoms of 
chest pain, shortness of breath, or dyspnea. The provider requested a CT of the heart for evaluation of coronary 
calcium. The review has determined that the requested CT scan is not medically necessary or reasonable. 
 
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 heart.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Mis sensor.  
You asked the Plan to pre-approve the Dexcom G7 Mis sensor. You say that the enrollee is hypervigilant with 
monitoring her blood sugars and is very anxious regarding her glucose. You also say that the enrollee did not 
have success with the FreeStyle Libre and think the Dexcom will be the best option for them. The Plan denied 
your request. The Plan says a CGM is not covered under Medicare if the member is not on insulin or does not 
have documentation of recurrent problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Dexcom G7 Mis sensor. Our 
reviewer says that the Dexcom G7 is not medically necessary. Our physician reviewer found the provided 
records do not document that the enrollee is insulin treated or has a history of problematic hypoglycemia. The 
criteria for the Dexcom G7 have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Dexcom G7 Mis sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 Mis sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sedation (D9239 and D9243). 
 
You asked the Plan to pre-approve the dental services. You say that the sedation is necessary because you 
cannot have the other dental procedures done without it. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because sedation 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
sedation (D9239 and D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) and limited oral evaluation - problem focused (D0140) provided on April 14, 2023, and April 21, 
2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images and limited oral evaluation 
- problem focused. You say that there was no frequency information provided at the time of the call and 
therefore the Plan should be paying for the services. The Plan denied your request. The Plan says your benefit 
for the requested services 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 intraoral - complete series of radiographic images was exhausted on date of service 
July 1, 2019. The limited oral evaluation - problem focused was exhausted on date of service February 16, 
2023. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of 
radiographic images (D0210) and limited oral evaluation - problem focused (D0140) provided on April 14, 
2023, and April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one on one strength training provided from January 1, 2023, 
to January 31, 2023. 
 
You asked the Plan to pay for one on one strength training. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services and/or facility are not eligible for fitness 
reimbursement. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $300 
per calendar year toward your club membership fees. One on one sessions do not qualify for this benefit. 
 
 
  The Plans rules for coverage of gym benefits have not been met because one on one sessions do not qualify for 
this benefit. The Plan rules also say that fees for personal training are excluded from this benefit. Therefore, we 
decided that the Plan does not have to pay for one on one strength training provided from January 1, 2023, to 
January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames and bifocal lenses provided on February 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you ran your insurance twice, and were told the 
insurance would cover your frames. The Plan denied your request. The Plan says that your benefit for the 
requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for frames and bifocal lenses provided on February 
18, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 months. You say that the services are necessary. The Plan 
denied your request. The Plan says ased on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator for 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found a home ventilator is not 
medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP) with average 
volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator for 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided by a chiropractor (99203, 99212), 
application of hot or cold packs (97010 x 4), mechanical traction (97012 x 4) and electrical stimulation (G0283 
x 4) provided from March 20, 2023, to March 30, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that these procedures are necessary to allow work 
to be done on your back and neck. The Plan denied your request. The Plan says these chiropractic services are 
excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visits provided by a chiropractor (99203, 99212), application of hot 
or cold packs (97010 x 4), mechanical traction (97012 x 4) and electrical stimulation (G0283 x 4) provided 
from March 20, 2023, to March 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 14, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that code 70450 should be paid as billed. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service May 14, 2023.