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

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 4, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided the 
documentation and would like the claim reprocessed. 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 a valid proof of delivery. Specifically, there was no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
periapical first x-ray (D0220) and retreatment of previous root canal therapy (D3347) provided on August 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay this claim and are 
appealing 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 items or services was exhausted on date of service August 24, 2023. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140), periapical first x-ray (D0220) and retreatment of previous root canal therapy (D3347) provided on 
August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on September 
13, 2023. 
 
You asked the Plan to pay for the dental service. You say that your dentist found a crack in your tooth that 
needed repair. You say that you believe this should be a covered benefit. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
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 service in this case not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite (D2392) provided on September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on September 6, 
2023. 
 
You asked the Plan to pay for the office visit. You say that you were told you had to pay a $20 copay for an 
adjustment. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. You say that you were told that you could use any chiropractor in or out of network 
and the Plan would pay 40%. 
 
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 provided by a chiropractor on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
the porcelain/ceramic pontic (D6245), and the porcelain/ceramic retainer crowns (D6740 x 2) provided on 
August 4, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items provided in this case 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 dental items provided are not 
among those covered under this benefit.   
Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required 
(D2950), the porcelain/ceramic pontic (D6245), and the porcelain/ceramic retainer crowns (D6740 x 2) 
provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the restorative procedure (D2999) provided on September 
13, 2023. 
 
You asked the Plan to pay for the restorative procedure. You say that the provider needed to remove a crown to 
determine the extent of decay and to create a treatment plan. The Plan denied your request. The Plan says this 
service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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 the 
restorative procedure (D2999) provided on September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on September 6, 
2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting a review of this claim. 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 provided by a chiropractor on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on August 
29, 2023. 
 
You asked the Plan to pay for the dental service. You say that you only had x-rays done. You also say that you 
do not know why there is a duplicate x-ray charge. The Plan denied your request. The Plan says your benefit 
for this service has 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 this service was exhausted in the processing of the claim for the date of service in this case, August 29, 2023. Therefore, we decided that the Plan does not have to pay for the additional periapical x-
ray (D0230) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of tooth for tooth #8 (D7210). 
 
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 your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical removal of tooth for tooth #8 (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on July 15, 2023, to July 
17, 2023. 
 
You asked the Plan to pay for  the acupuncture services. You say that you were advised that the service as not 
covered. The Plan denied your request. The Plan says that acupuncture is only covered for chronic low back 
pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have been diagnosed with hereditary and 
idiopathic neuropathy, and acupuncture is only covered for chronic low back pain. Therefore, we decided that 
the Plan does not have to pay for the acupuncture services provided on July 15, 2023, to July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 
87651, 87653, and 87798 for date of service August 29, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87481, 87640, 87651, 87653, and 
87798. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 87651, 87653, and 87798 
for date of service August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675, E0650) and a heating pad pump (E0236).

You asked the Plan to pre-approve the pneumatic compression device and heating pad pump. You say that these items are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. The rules state that claims for E0675 will be denied as not reasonable and necessary. The rules also state that because a water circulating heating pad system is not medically necessary, a replacement pump (E0236) is non-covered.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. Under Medicare rules, a heating pad is also non-covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0675, E0650) and a heating pad pump (E0236).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-periapical first radiographic image (D0220) and 
the surgical placement of implant body: endosteal implant (D6010) provided on June 27, 2023. 
 
 You asked the Plan to pay for an intraoral-periapical first radiographic image and the surgical placement of 
implant body: endosteal implant. You say that the radiographic imaging and the endosteal implant are 
medically necessary to restore your tooth to its pre-accident condition, allowing you to bite and chew food as 
you did before the accident. You say the damage to your tooth was not caused by a biting incident; it was 
caused by external trauma from an accident and should be covered by your medical plan. The Plan denied your 
request. The Plan says the implant service is not a covered benefit under the plan. The Plan says that your 
benefit for the intraoral x-ray has already been exhausted. The Plan also says the services involve the care, 
treatment, filling, removal or replacement of teeth or structures directly supporting the teeth and therefore, 
would be excluded from coverage under the medical benefit. 
 
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. Charges for 
any type of implant are not covered under this benefit. The record shows your benefit for the intraoral x-ray 
was exhausted on date of service January 16, 2023. The requested items or services are also not eligible for 
coverage under the medical benefit. Therefore, we decided that the Plan does not have to pay for an intraoral-
periapical first radiographic image (D0220) and the surgical placement of implant body: endosteal implant 
(D6010) provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 13, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
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, we have confirmed that code 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service June 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would fail at a lower level of 
care, and an LTACH will be able to attend to their ongoing needs. The Plan denied your request. The Plan says 
they will continue to cover medically necessary acute and critical care at the current facility until the member's 
condition is stable for transfer to an alternate level of care (such as a skilled nursing facility), or until the 
clinical circumstances change such that LTACH may be reconsidered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nebulizer with compression (E0570) provided on July 
11, 2023. 
 
You asked the Plan to pay for the Nebulizer with compression (E0570). You say that the provided Nebulizer 
with compression was medically necessary. The Plan denied your request. The Plan says the enrollee did not 
meet criteria for the provided Nebulizer with compression. 
 
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 the Nebulizer with compression (E0570). 
Our reviewer says that the enrollee did not meet criteria for the provided Nebulizer with compression. Our 
physician reviewer found the delivery method of the nebulizer does not meet criteria for compressors. Can be 
delivered with standard nebulizer. Hence, no indication for compressor delivered nebulizer. 
 
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 Nebulizer with compression (E0570) have not been met. Therefore, we 
decided that the Plan does not have to pay for the Nebulizer with compression (E0570) provided on July 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor kit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are 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. The documentation indicates that the enrollee does not treat with 
insulin or have a history of problematic hypoglycemia with documentation of recurrent level two hypoglycemic 
events. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM) sensor kit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on January 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were lifesaving for you and should be covered. The Plan denied your request. The Plan says 
without transport there are no payable services. 
 
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 January 24, 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 without 
transport services received on January 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary, and you were not aware of the no transport policy. The Plan denied your 
request. The Plan says without transport there are no payable services. 
 
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 August 8, 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 without 
transport services received on August 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy. provided on July 07, 2023, to August 21, 
2023. 
 
You asked the Plan to pay for physical therapy.. You say that the services were medically necessary. 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 physical therapy. 
provided on July 07, 2023, to August 21, 2023.