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

 
We decided that the Plan does not have to pre-approve the Shock Reducing Pylon (L5988) and Supracondylar 
Suspension System (L5670). 
 
You asked the Plan to pre-approve the Shock Reducing Pylon and Supracondylar Suspension System. You say 
that the items are medically necessary. The Plan denied your request. The Plan says there is no indication the 
member requires a shock reducing pylon and the requested suspension is a duplicate request. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot or knee. 
Medicare considers equipment to be reasonable and necessary if the equipment does not serve the same 
purpose as other equipment already available to an 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 Shock Reducing Pylon and 
Supracondylar Suspension System. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no indication the member requires 
a shock reducing pylon and the requested suspension is a duplicate request. 
 
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 Shock Reducing Pylon and Supracondylar Suspension System have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Shock Reducing Pylon (L5988) 
and Supracondylar Suspension System (L5670).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the requested services. You say that IGRT is a covered service. The Plan 
denied your request. The Plan says the approved radiation does not require daily imaging. 
 
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 requested services. Our physician 
reviewer found that when treating skin cancers, there is generally not a need for IGRT unless deep structures 
are being treated. Daily simple simulations and/or IGRT for a technology for which need has not been 
established by published data or supported by consensus guidelines is not necessary. Daily IGRT would not be 
furnished in accordance with accepted standards of medical practice. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for checkup examination (D0120) provided on December 14, 
2022. 
 
You asked the Plan to pay for 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 pay for checkup examination (D0120) provided on December 14, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from July 27, 2022, to 
July 31, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
services would not be covered. Without this information, we cannot determine whether the SNF order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the skilled nursing facility 
(SNF) care provided from July 27, 2022, to July 31, 2022.  
 
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: 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 the enrollee is at risk of aspiration, 
infection, seizures, and wound development. You also say the LTACH can render services that cannot be 
rendered at a lower level of care, and you would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee does not meet all the requirements for admission to the 
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 the 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: 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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to the 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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on June 17, 2022. 
 
You asked the Plan to pay for injections. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
June 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. You say that you recommend the enrollee have repeat a EGD this 
year to screen for esophageal varices. The Plan denied your request. The Plan says this request cannot be 
approved. 
 
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 an EGD. Our reviewer says that an 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found available 
records support significant co-morbidities for the enrollee that place them at substantial risk of elective EGD. 
No pathology was identified by the EGD from April 27, 2023, to warrant as medically appropriate nor 
necessary a repeat EGD study at this time. Our reviewer also found that the provided records do not support an 
expectation of Barrett's esophagus based on endoscopic description, nor were imaging criteria provided to 
support concern for interval development of portal hypertension with varices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 23, 2021. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to receive 
the proper rehab services to regain and maintain function. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting such as a skilled nursing facility, home 
with home health services, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260), bone replacement grafts 
(D4263, D4264), and guided tissue regeneration (D4266). 
 
 
You asked the Plan to pre-approve osseous surgery, bone replacement grafts and guided tissue regeneration. 
You say that these should be covered. The Plan denied your request. The Plan says these are not covered 
services. 
 
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 
osseous surgery (D4260), bone replacement grafts (D4263, D4264), and guided tissue regeneration (D4266).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the debridement procedures and the 
application of compression systems provided from September 12, 2022, to October 27, 2022. 
 
You asked the Plan to waive the copayments for the debridement procedures and the application of 
compression systems. You say that you were told you would not have a charge. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
 You have been asked to pay up to a $295 copayment for each outpatient surgical procedure provided from 
September 19, 2022, to October 27, 2022.  These items/services fall within the outpatient surgery and other 
medical services provided at hospital outpatient facilities benefit category. 
 
Date of Service Code Copayment Member Responsibility 
September 12, 2022 11042 $295 $295 
September 19, 2022 11043 $295 $295 
September 21, 2022 29581 $295 $133.05 
September 23, 2022 29581 $295 $133.05 
September 26, 2022 29581 $295 $133.05 
September 28, 2022 29581 $295 $133.05 
September 30, 2022 29581 $295 $133.05 
October 3, 2022 11042 $295 $295 
October 6, 2022 11042 $295 $295 
October 10, 2022 11042 $295 $295 
October 13, 2022 11042 $295 $295 
October 17, 2022 97597 $295 $169.12 
October 20, 2022 97597 $295 $169.12 
October 24, 2022 97597 $295 $169.12 
October 27, 2022 29581 $295 $133.05 
 
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 copayments for the debridement procedures and the application of 
compression systems provided from September 12, 2022, to October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) Tooth #29 provided on October 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services received should not have been 
denied, the enrollee is able to receive treatment to extract one tooth per calendar year. 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 D0330 but is limited to one procedure code every five calendar years and D7210 but is limited to two 
procedure codes per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0330 on March 9, 2021, and received covered D7210 Tooth #20 and 28 on 
October 26, 2022. Therefore, these benefits were exhausted as of October 26, 2022. Therefore, we decided that 
the Plan does not have to pay for panoramic radiographic image (D0330) and extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210) Tooth #29 provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable unilateral partial denture  one piece resin 
(including retentive/clasping materials, rests, and teeth)  per quadrant (D5286). 
 
You asked the Plan to pre-approve the removable unilateral partial denture. You say that you thought this 
service was covered by your plan. 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 removable unilateral partial denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve removable unilateral partial denture  one piece resin (including retentive/clasping materials, rests, and 
teeth)  per quadrant (D5286).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 
30, 2022 to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 30, 2022 to December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported cast metal crown (predominantly 
base metal) (D6063 x7), and implant supported crown - porcelain fused to high noble alloys (D6066 x7). 
 
You asked the Plan to pre-approve the abutment supported cast metal crown and implant supported crown. You 
say that you cannot chew and cannot afford the implants. The Plan denied your request. The Plan says these 
services are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
abutment supported cast metal crown (predominantly base metal) (D6063 x7), and implant supported crown - 
porcelain fused to high noble alloys (D6066 x7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (T2003 and T2004). 
 
You asked the Plan to pay for procedure code T2003 and T2004. You say that transfer of care to a facility is 
necessary for medical management. The Plan denied your request. The Plan says this service is not valid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes T2003 and T2004 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure code T2003 and T2004 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure code T2003 and T2004 have not been 
met. Therefore, we decided that the Plan does not have to pay for transportation services (T2003 and T2004).