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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that that the proper workup for the detected 4.8 cm 
liver mass is a magnetic resonance imaging (MRI) using 3 phase technique. The PET scan is not indicated at 
this time. The Plan denied your request. The Plan says the requested PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found a positron emission tomography (PET) 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an IRF 
admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile, but also sufficiently stable at this juncture for 
management in an IRF setting. There is every reason to expect that the enrollee will participate in and benefit 
from an IRF level of services that might be needed to make a sustainable return home as well as avoid 
preventable readmissions to the acute hospital. Therefore, the requested inpatient rehab facility admission is 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization indicates that the enrollee 
does not have diabetes. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on December 9, 2022. 
 
You asked the Plan to reimburse for hearing aids. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says there was no referral or authorization on file for these services. The 
Plan also says that routine hearing examinations and/or hearing aids must be rendered by a participating Plan 
hearing 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 you contact the Plan hearing vendor prior to obtaining the hearing aids and when the 
hearing aids through a Plan hearing vendor.  
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on February 6, 
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 full 
mouth debridement (D4355) provided on February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 87798, 87640, 87634, 87581, 87502, 87498, 87486, 87633, 
87651, and U0003 for date of service May 16, 2023. 
 
You asked the Plan to pay for 87798, 87640, 87634, 87581, 87502, 87498, 87486, 87633, 87651, and U0003. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services 
billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87798, 87640, 87634, 87581, 87502, 87498, 87486, 87633, 87651, and U0003 are not 
supported in the medical record. Specifically, codes 87798, 87640, 87634, 87581, 87502, 87498, 87486, 87633, 
and 87651 are bundled with code U0003. In addition, Code U0003 will no longer be payable for dates of 
service on or after May 12, 2023. As this date of service was after May 12, 2023, the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 87798, 87640, 87634, 87581, 
87502, 87498, 87486, 87633, 87651, and U0003 have not been met. Therefore, we decided that the Plan does 
not have to pay for 87798, 87640, 87634, 87581, 87502, 87498, 87486, 87633, 87651, and U0003 for date of 
service May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid charger (V5274) purchased 
on April 25, 2023. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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.  
 
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 this item have not been met. Specifically, a hearing aid charger is not a covered benefit. Therefore, 
we decided that the Plan does not have to issue reimbursement for the hearing aid charger (V5274) purchased 
on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a retainer crown (D6750) for tooth #20 and to pay for a 
retainer crown (D6750) for tooth #21 provided on March 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have a $2,000 benefit and you would 
like the reimbursement checks sent to you. The Plan denied your request. The Plan says your maximum dental 
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 $183 for dental services on January 30, 2023, and February 8, 2023. On March 9, 2023, 
the Plan paid $1,817 for dental services. For the year of 2023 the Plan paid $2,000 ($183 paid + $1,817 paid) 
for dental services; therefore, your maximum dental benefit for the year of 2023 was exhausted on the date of 
service of March 9, 2023. Therefore, we decided that the Plan does not have to pay more for a retainer crown 
(D6750) for tooth #20 and to pay for a retainer crown (D6750) for tooth #21 provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve to repair false teeth (D5650) and surgical extraction for 
tooth 11 (D7210). 
 
You asked the Plan to pre-approve to repair false teeth and surgical extraction for tooth 11. You say that the 
tooth is causing you pain and discomfort and 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 to repair false teeth (D5650) and surgical extraction for tooth 11 (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and bifocal eyeglass lenses (V2202) 
provided on July 19, 2023.  
You asked the Plan to pay for frames (V2020) and bifocal eyeglass lenses (V2202). You say that according to 
your coverage documents, there is an allowance of up to $200 per year for prescription eyewear. You also say 
the claim barely exceeds that amount. The Plan denied your request. The Plan says the service is a covered 
benefit, but you have exceeded limits set in the subscriber agreement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 allowance every calendar year that you can use to pay for eyewear to correct 
vision. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan provides a $200 allowance every 
calendar year that you can use to pay for eyewear to correct vision. The record shows this benefit was 
exhausted. Based on this information, we decided that the Plan's rules for coverage of frames (V2020) and 
bifocal eyeglass lenses (V2202) have not been met. Therefore, we decided that the Plan does not have to pay 
for frames (V2020) and bifocal eyeglass lenses (V2202) provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional pontics and retainer crowns (D6240, D6752) 
provided on April 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 11, 2023. 
Therefore, we decided that the Plan does not have to pay for additional pontics and retainer crowns (D6240, 
D6752) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 May 1, 2023. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided on April 1, 2023. 
 
You asked the Plan to reimburse for a gym membership. You say that you did not have enough time to gather 
documents, which are now submitted. The Plan denied your request. The Plan says you were not active on the 
Plan from January to March. The Plan also says that you did not submit for reimbursement for the remaining 
$245.03. 
 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a gym membership  have been met. 
missing the addition proof of payment for the remaining $245.03 towards the gym membership. Therefore, we 
decided that the Plan does not have to reimburse for a gym membership provided on April 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's current condition requires an IRF level 
of care. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for 
an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is in fact complex and fragile, but also sufficiently stable at this juncture for 
management in an IRF setting. There is every reason to expect that the enrollee will participate in and benefit 
from an IRF level of services that might be needed to make a sustainable return home as well as avoid 
preventable readmissions to the acute hospital. Therefore, the requested inpatient rehab facility admission is 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radiofrequency Ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of the sacroiliac joint is not considered 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation of the sacroiliac joint have not been met. Specifically, radiofrequency 
ablation of the sacroiliac joint is not considered medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral x-rays and panoramic x-ray (D0230, 
D0330) provided on May 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 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 May 11, 2023 (D0230) 
and September 9, 2022 (D0330). Therefore, we decided that the Plan does not have to pay for additional 
intraoral x-rays and panoramic x-ray (D0230, D0330) provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure and periodontal scaling 
and root planing (D1999, D4341, D4342) provided on June 16, 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 your benefit for periodontal scaling and root 
planing has already been exhausted. Additionally, the unspecified preventive procedure 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 15, 2022 (D4341, 
D4342). Additionally, the unspecified preventive procedure denied correctly as they do not fall within your 
dental benefits. Therefore, we decided that the Plan does not have to pay for an unspecified preventive 
procedure and periodontal scaling and root planing (D1999, D4341, D4342) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim retainer crown for teeth #28 and #29 and interim 
pontic for tooth #29 (D6793, D6253) provided on July 12, 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 an interim 
retainer crown for teeth #28 and #29 and interim pontic for tooth #29 (D6793, D6253) provided on July 12, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on April 18, 2023. 
 
You asked the Plan to pay for procedure code G0482. 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. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code G0482 based on Medicare criteria. There are no listed National Correct Coding 
Initiative (NCCI) Edits to indicate that procedure codes G0482 and 80307 cannot be billed together for 
payment. The Plan provided no Medicare regulations confirming that these codes cannot be billed on the same 
date of service. Therefore, we decided that the Plan has to pay for procedure code G0482 provided on April 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.