Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation (ERFA) right C1 perforator, right 
C3 perforator (36475 x 2). 
 
You asked the Plan to pre-approve the ERFA for the right C1 and C3 perforators. You say that the requested 
procedures are medically necessary for the enrollee. The Plan denied your request. The Plan says the 
endovenous ablation of the right C1 and C3 perforators do not satisfy the criteria that varicosities must be of 
the lesser or greater saphenous veins to be covered for ERFA.  
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation (ERFA) or laser ablation is 
indicated when certain criteria have been met. 
 
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 endovenous ablation for the right 
C1 and C3 perforators. Our reviewer says that the requested endovenous ablation for the right C1 and C3 
perforators is not medically necessary. Our physician reviewer found the documentation does not meet 
coverage criteria and does not support the medical necessity of the procedures in question.  The reviewer found 
there is no documentation that the enrollee has venous stasis ulcers refractory to other efforts. The reviewer 
found that the enrollee is also being scheduled for numerous endovascular procedures, the majority of which 
apparently has already been approved and is interested in spider vein (cosmetic for the purpose of this review) 
treatment. Therefore, the reviewer found that the requested procedures are 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 endovenous ablation for the right C1 and C3 perforators have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endovenous ablation (ERFA) right C1 
perforator, right C3 perforator (36475 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
resin-based composite-one surface, anterior for tooth number 24 (D2330), and the endodontic therapy, of an 
anterior tooth (excluding final restoration) for tooth number 23 (D3310) provided on September 26, 2022. 
 
You asked the Plan to pay for the dental 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 services provided 
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 services provided has already been exhausted. The Plan contract states that the 
maximum allowable dental benefit per calendar year is $2,500. The record shows that the Plan issued payments 
for the total amount of $2,500 ($182 + $277, + $416, +$564, + $188, + $120, +$753) for dental services 
provided in the 2022 calendar year. Therefore, you have exhausted the allowable benefit for these services. 
Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic image 
(D0220), resin-based composite-one surface, anterior for tooth number 24 (D2330), and the endodontic 
therapy, of an anterior tooth (excluding final restoration) for tooth number 23 (D3310) provided on  
September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cleaning and maxillary partial denture (D5213, 
D4342). 
 
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 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 pre-approve a 
cleaning and maxillary partial denture (D5213, D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
February 13, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation for routine dental care.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The service you are asking the Plan to pre-approve involves the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
sedation for routine dental care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy services billed with code 97026 on date of 
service September 6, 2022. 
 
You asked the Plan to pay for the infrared therapy services. You say that the patient had insurance coverage on 
the date of service. The Plan denied your request. The Plan says infrared therapy is not covered. The Plan must 
follow Medicare rules. Medicare rules say that infrared therapy is non-covered. Therefore, we decided that the 
Plan does not have to pay for infrared therapy services billed with code 97026 on date of service September 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 provided on November 22, 2022. 
 
You asked the Plan to pay for procedure code 99204. You say that the medical records support the billing of 
code 99204. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99204. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
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 procedure code 99204. Our reviewer says that the medical 
records do not support the billing of code 99204. Our reviewer found the enrollee was evaluated on November 
22, 2022, for right shoulder pain. She was diagnosed with a partial thickness rotator cuff tear and received a 
subacromial injection. The review indicates that the medical records supported a medically appropriate history 
and/or examination but not a moderate level of medical decision making. Current Procedural Terminology 
(CPT) code 99204-25 (1 unit) was not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99204 provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine months of continued use of a non-invasive 
ventilator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may not be covered when they are intended 
to be used to provided CPAP or BiPAP. 
 
The records appear to show that the ventilator is intended to be used on average volume-assured pressure 
support (AVAPS) mode with BIPAP. 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 pre-approve nine 
months of continued use of a non-invasive ventilator.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular and maxillary partial denture (D5225, D5226). 
 
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 a mandibular and maxillary partial denture 
(D5225, D5226).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care services provided on 
November 14, 2022. 

You asked the Plan to pay for nursing facility care services. You say that other claims have been paid for the enrollee and ask for reconsideration of the payment. 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 subsequent nursing facility care services provided on 
November 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 7, 2023. 
 
You asked the Plan to pay for self-administered drugs . You say that that you are disabled with type 1 diabetes 
and your life depends on your daily Humalog insulin injections. The Plan denied your request. The Plan says 
that self-administered drugs do not fall under Medicare Part B coverage. 
 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 self-administered drugs provided 
on February 7, 2023.  
 
Benefits for 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this service is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for a spinal cord stimulator 
implant trial. The Plan contends you did not have a psychology evaluation or a surgical evaluation.  
The Plan must follow Medicare rules. Medicare rules say that patients must have undergone careful screening, 
evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include 
psychological, as well as physical evaluation). In this case, there is no evidence that a surgical consultation has 
occurred.  If you have records from such a consultation, you may send those to the Plan directly. 
 
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 spinal cord stimulator trial. Our 
reviewer says that a spinal cord stimulator is not medically reasonable and necessary at this time. Our physician 
reviewer found there is no evidence of a surgical consultation having been submitted. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) and the therapeutic parenteral drugs, two or more 
administrations, of different medications (D9612) provided on November 17, 2022. 
 
You asked the Plan to pay for these 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 these 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 Plans coverage rules apply in this case. 
  
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation-diagnostic service provided by a dentist or physician other than requesting dentist or physician 
(D9310) and the therapeutic parenteral drugs, two or more administrations, of different medications (D9612) 
provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary and mandibular dentures (D5110, 
D5120). 
 
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 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 December 9, 2019. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary and mandibular dentures 
(D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system (L5910). 
 
You asked the Plan to pre-approve the services. You say that this will provide more range of motion. The Plan 
denied your request. The Plan says the notes do not show why enrollee's current alignable system cannot be 
used for approved replacement socket. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not indicate the current alignable system cannot be added to the new prosthesis. The 
request exceeds what is necessary to meet the enrollee's needs. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an alignable system (L5910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture, mandibular partial denture, 
and medical anesthesia (D5213, D5214, D9500). 
 
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 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 pre-approve a 
maxillary partial denture, mandibular partial denture, and medical anesthesia (D5213, D5214, D9500).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine test provided on February 24, 2023. 
 
You asked the Plan to pay for a urine test. You say that the enrollee does not have the option on which lab 
service to use. 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 a urine test provided on 
February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an OON provider. 
 
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 dental services from an out-of-network provider are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services with an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 10, 2023. 
 
You asked the Plan to pay for wound care services. You say that the records attached support the services 
provided. 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 wound care services 
provided on January 10, 2023.