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

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214), a pontic (D6240) for 
tooth #12 and #13, and a retainer crown (D6752 and D6792) for tooth #11 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you should have been enrolled into 
different coverage. The Plan denied your request. The Plan says the denial of authorization for the pontics and 
retainers crown is correct because the documentation does not meet the criteria for coverage. Also, dentures are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers bridges when 
the services are medically necessary and reasonable.  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 dental services. Our reviewer says 
that the pontic (D6240) for tooth #12 and #13 and the retainer crown (D6752 and D6792) for tooth #11 and #14 
is not medically necessary. Our physician reviewer found that the x-rays show severe bone loss around teeth 
#11 and #14. The periodontal prognosis for the tooth is guarded-poor due to the amount of bone loss around 
these teeth. The crown to root ratio of tooth #14 is poor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. The lower partial denture is 
not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pre-approve a 
lower partial denture (D5214), a pontic (D6240) for tooth #12 and #13, and a retainer crown (D6752 and 
D6792) for tooth #11 and #14.  
 
Your complaint about what coverage you were supposed to be enrolled in is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incisional biopsy of oral tissue soft (D7286) provided on 
June 2, 2023. 
 
You asked the Plan to pay for incisional biopsy of oral tissue-soft. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 incisional 
biopsy of oral tissue soft (D7286) provided on June 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849), provided on June 25, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was needed or ordered prior to receiving the item in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the traction 
equipment (E0849), provided on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 20, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are requesting reconsideration for the 
denied claim. 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 practitioner services 
provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive health services provided on April 03, 2023. 
 
You asked the Plan to pay for preventive health services. You say that you are requesting reconsideration for 
the denied claim. 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 preventive health 
services provided on April 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 skin substitute (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega3 skin substitute. You say that this is medically necessary. 
The Plan denied your request. The Plan says the records do not show that you have failed to respond to 
standard wound care. This is 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 pre-approve Kerecis Omega3 skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Kerecis Omega3 skin substitute is not standard of care and 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 Kerecis Omega3 skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Kerecis Omega3 skin substitute (Q4158).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denosumab injection (J0897). 
 You asked the Plan to pre-approve a denosumab injection. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 denosumab injection. Our reviewer 
says that the Plan's step therapy requirements have not been met. Our physician reviewer found the enrollee has 
not tried and failed the Plan's required drug(s)and there is no documentation provided indicating that the plans 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 denosumab injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a denosumab injection (J0897).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
21, 2023, to February 19, 2023. 
 You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act.  The Plan denied your request. The Plan says custodial care is not a covered expense. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from January 21, 2023, to February 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring Active Non-Pneumatic 
Compression Garment System (K1024 and K1032). 
 
You asked the Plan to pre-approve the Koya Dayspring Active Non-Pneumatic Compression Garment System. 
You say that the item is medically necessary. The Plan denied your request. The Plan says this item is 
considered experimental. 
 
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 Koya Dayspring Active Non-
Pneumatic Compression Garment System. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this item is considered 
experimental.  
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 Koya Dayspring Active Non-Pneumatic Compression Garment System have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring Active 
Non-Pneumatic Compression Garment System (K1024 and K1032).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive percutaneous sacroiliac (SI) fusion 
(27279). 
 
You asked the Plan to pre-approve a minimally invasive percutaneous SI fusion. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. You have 
multifactorial sources for pain to the lumbosacral region. 
 
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 a minimally invasive percutaneous SI 
fusion. 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 SI joint instability fracture or lesion. SI joint 
fusion for degenerative back pain is experimental.  
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 minimally invasive percutaneous SI fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a minimally invasive percutaneous sacroiliac (SI) fusion 
(27279).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says these services are not a covered benefit.  
 
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 April 15, 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 the ambulance response and treatment with no 
transport provided on April 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 14, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 25, 2023, billed with 
procedure code 99236. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation does not support 
either a high level of medical decision making or more than 85 minutes of total time on the encounter date. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 25, 2023, billed with procedure code 
99236.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 29, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 home visit evaluation 
provided on June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A4239 billed for date of service April 26, 2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says that the code is 
bundled. 
 
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 A4239 is supply allowance for non-adjunctive, non-
implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit 
of service 
 
We find that CPT code A4239 is supported. Code A4239 includes all necessary items for use of the continuous 
glucose monitor. Any additional supplies billed are considered bundled and not separately payable. In this case, 
no other supplies were billed besides the payable allowance code A4239. Based on this information, we 
decided that Medicare rules for coverage of the billed service have been met. Therefore, we decided that the 
Plan has to pay for procedure code A4239 billed for date of service April 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.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan must pre-approve a magnetic resonance imaging (MRI). We decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan.  
 
You asked the Plan to pre-approve a magnetic resonance imaging and a computed tomography scan. You say 
that requested services are medically necessary for the enrollee. The Plan says that the physician directed 
treatment did not occur within the last three months, symptoms must be the same or worse after treatment to 
support imaging and there was no contact with the physician after completing treatment. 
 
We decided that the Plan must pre-approve a magnetic resonance imaging service (MRI).  
 
 Therefore, we decided that the Plan must pre-approve a magnetic resonance imaging service (MRI).   
We also decided that the Plan does not have to pre-approve a computed tomography (CT) scan . 
 
 Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan . 
 
Our physician found that criteria for MRI lumbar spine have been met.  Medical necessity of the CT abdomen 
and pelvis has not been established in the submitted records. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  therapeutic pulpotomy (D3220) provided 
on August 15, 2023. 
 
You asked the Plan to waive the coinsurance for  therapeutic pulpotomy. You say that this was medically 
necessary. 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 50% 
coinsurance for comprehensive dental services.  
 
You have been asked to pay 50% coinsurance for therapeutic pulpotomy. This item/service falls within the 
Comprehensive dental benefit category. 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 coinsurance for  
therapeutic pulpotomy (D3220) provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0367 and D0180) on July 6, 2023. 
 
You asked the Plan to pay for the dental services (D0367 and D0180). You say that you would like to request 
reconsideration for payment. 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.  
 
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. Therefore, we decided that the Plan does not have 
to pay for the dental services (D0367 and D0180) on July 6, 2023.