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

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) and the intraoral-periapical additional radiographic image (D0230) provided on May 24, 2023. 
 
You asked the Plan to pay for the items/services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the intraoral x-ray provided 
has already been exhausted. Additionally, drugs or medicaments dispensed in the office for home use are not 
covered under the 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, certain limitations apply. The record 
shows your benefit for the intraoral x-ray provided was exhausted on date of service May 24, 2023. 
Specifically, the Plans contract states that one intraoral x-ray is covered per year. On this day, you received 
two intraoral x-rays, in which one was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for this service. Additionally, drugs or medicaments dispensed in the office for home use are not 
covered under the supplemental dental policy. Therefore, we decided that the Plan does not have to pay for the 
drugs or medicaments dispensed in the office for home use (D9630) and the intraoral-periapical additional 
radiographic image (D0230) provided on May 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on July 17, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were feeling better 
after treatment and did not need to go to the hospital. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), the manual therapy techniques 
(97140) and the mechanical traction therapy (97012) provided by a chiropractor on July 6, 2023, to, July 10, 
2023. 
 
You asked the Plan to pay for the office visit (99203), the manual therapy techniques (97140) and the 
mechanical traction therapy (97012). You say that you have a bulging disc which cannot be fixed by a physical 
therapist. You say that you do not know where else to go as this treatment has been helping. You say that you 
hurt your neck when you attempted to pick 60 pounds of cat litter. The Plan denied your request. The Plan says 
the only covered chiropractic service is manual manipulation of the spine. 
 
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 visit (99203), the manual therapy techniques (97140) and the 
mechanical traction therapy (97012) provided by a chiropractor on July 6, 2023, to, July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion surgery with Inspan device (22840, 
22612). 
 
You asked the Plan to pre-approve lumbar fusion surgery with Inspan device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 lumbar fusion surgery with Inspan 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested lumbar fusion with Inspan device is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion surgery with Inspan device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lumbar fusion surgery with Inspan device (22840, 22612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on September 11, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 a dental 
consultation (D9310) provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve complete maxillary dentures (D5110). 
 
You asked the Plan to pre-approve 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 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 pre-approve complete maxillary dentures (D5110).  
 
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 FreeStyle Libre 3 reader and sensors.  
You asked the Plan to pre-approve the FreeStyle Libre 3 reader and sensors. You say that the enrollee will be 
traveling to the east coast and will be gone for 2 years on a mission. You also say that as a result, it would be 
very difficult for him to check his sugar routinely. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare coverage for the CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Libre 3 reader and sensors have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 3 reader and sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630 x 2), a bone replacement graft for ridge preservation-per site (D7953), closure of a salivary fistula 
(D7983), and the placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization, per 
site (D7922 x 2). 
 
You asked the Plan to pre-approve these 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 items/services are not covered 
under the 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items and services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
drugs or medicaments dispensed in the office for home use (D9630 x 2), a bone replacement graft for ridge 
preservation-per site (D7953), closure of a salivary fistula (D7983), and the placement of an intra-socket 
biological dressing to aid in hemostasis or clot stabilization, per site (D7922 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, pulp vitality 
tests, limited oral evaluation, and intraoral x-rays (D0364, D0460, D0140, D0220) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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. Coverage for cone beam CT scans and 
pulp vitality tests denied correctly as they do not fall within your dental 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. Moreover, this benefit does not include cone beam 
CT scans or pulp vitality tests.  Therefore, we decided that the Plan does not have to pay for a cone beam 
computed tomography (CT) scan, pulp vitality tests, limited oral evaluation, and intraoral x-rays (D0364, 
D0460, D0140, D0220) provided on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on July 24, 2023.
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 you will be having valve replacement surgery soon 
and the inpatient rehab you have been denied will make you stronger beforehand and will give you a better 
outcome. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you 
are requesting do not meet the requirements for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on August 03, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee was in a nursing 
home setting at the time services were rendered. 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 principal care 
management services provided on August 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracapsular cataract removal with insertion of intraocular 
lens prosthesis (66984) provided on August 2, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for extracapsular cataract removal with insertion of intraocular lens prosthesis with 
an out-of-network provider. You say that you want the Plan to pay for the service. The Plan denied your 
request. The Plan says this provider is out-of-network, and no authorization was obtained. 
 
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. 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 extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) provided on August 2, 2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that enrollee's continued care in a SNF facility 
is medically necessary. The Plan denied your request. The Plan says the enrollees 100-day SNF benefit has 
been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 12, 2023, to 
October 23, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bioimpedance spectroscopy (BIS) (93702), and non-
ophthalmic fluorescent vascular angiography (C9733) provided on July 26, 2023. 
 
You asked the Plan to pay for bioimpedance spectroscopy, and non-ophthalmic fluorescent vascular 
angiography. You say that this was medically necessary. The Plan denied your request. The Plan says this was 
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 pay for bioimpedance spectroscopy, and non-
ophthalmic fluorescent vascular angiography. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found BIS is not current 
supported in the literature without high quality evidence to show its long-term benefit compared to other testing 
methods. Also, the complete assessment of this patient including history and physical prior to the procedure 
were not provided for review to better understand the context of this request and to see if this case is an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy, and non-ophthalmic fluorescent vascular 
angiography have not been met. Therefore, we decided that the Plan does not have to pay for bioimpedance 
spectroscopy (BIS) (93702), and non-ophthalmic fluorescent vascular angiography (C9733) provided on July 
26, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0481 provided on July 26, 2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that code G0481 is bundled into payment for 
code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has withdrawn the rule stating that code 
G0481 is bundled into code 80307. Code G0481 is now separately payable from code 80307 in accordance 
with the bulletin that CMS published on its website along with the 2023 Q4 NCCI files.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0481 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0481 provided on July 26, 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.