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

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for tooth #24 and 
#25.  
 
You asked the Plan to pre-approve the dental services. You say that you have a rare condition and the 
medication you take for it has caused damage to your teeth, so the bone grafts are necessary. The Plan denied 
your request. The Plan says the denial of authorization for these services is correct, because the bone 
replacement graft is 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. 
 
  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 
bone replacement graft (D4263) for tooth #24 and #25.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3020).  
 
You asked the Plan to pre-approve foot orthotics. You say that you are a diabetic and without the inserts you 
have bad balance. You also need the inserts because you wear shoes in the house. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   Records show that the requested foot inserts (L3020) are not a covered inserts for a persons with diabetes, and 
you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of the requested foot inserts. Therefore, we decided that the Plan does not have to pre-
approve foot inserts (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional rides for your 
upcoming appointments and surgery which are medically necessary. You also say that you need these rides for 
16 more weeks, 3 rides per week to and from your physical therapy.  The Plan denied your request. The Plan says transportation benefits beyond the 100 allotted one-way trips are 
not covered under the Medicare program or the Plan. The Plan also says that as of August 30, 2023, you have 
used or scheduled 100 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22511). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria is not met. The pain is multifactorial with 
multilevel disc disease. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
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 L2 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found there is no trial of a back brace 
for fracture treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22511).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675), provided on 
November 19, 2022, through December 6, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675), provided on November 19, 2022, through December 6, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from 
February 4, 2023, to March 5, 2023. 
 
You asked the Plan to pay for the SNF stay. You say that the SNF stay should be covered under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee has exhausted the 100-day SNF benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 30, 2022, 
to February 3, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from February 4, 2023, to 
March 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on December 31, 
2022. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 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 does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation for moderate sedation, deep sedation or 
general anesthesia (D9219) and deep sedation/general anesthesia-each subsequent 15 minute increment 
(D9223). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested 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 requested services are not among 
those covered under this benefit.   
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve an evaluation for moderate sedation, deep 
sedation or general anesthesia (D9219) and deep sedation/general anesthesia-each subsequent 15 minute 
increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic pontics (D6245 x 4), custom 
fabricated abutments-includes placement (D6057 x 2), and abutment supported porcelain/ceramic crowns 
(D6058 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental items/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 items from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested dental items are not covered under this benefit when received from 
an out-of-network provider. Additionally, custom fabricated abutments and abutment supported crowns are not 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic 
pontics (D6245 x 4), custom fabricated abutments-includes placement (D6057 x 2), and abutment supported 
porcelain/ceramic crowns (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
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. 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an incisional 
biopsy of oral tissue (D7286).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional trips. 
 
You asked the Plan to pre-approve 10 additional trips. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says you have exceeded your benefit limit. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 84 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 17, 
2023, to April 15, 2023. 
 
You asked the Plan to pay for SNF care. You say that continued stay at a skilled nursing facility was medically 
necessary. The Plan denied your request. The Plan says continued stay at a skilled nursing facility was not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 30, 2022, 
to February 3, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 17, 2023, to 
April 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total shoulder replacement (23472). 
 
You asked the Plan to pre-approve a total shoulder replacement. You say that this is medically necessary. The 
Plan denied your request. The Plan says records do not show evidence of rotator cuff tear or injury or any other 
shoulder pathology to support a reverse shoulder arthroplasty.  
 
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 total shoulder replacement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a right shoulder magnetic 
resonance imaging that corroborates any rotator cuff pathology or any other pathology of the right shoulder that 
would support the medical necessity of the requested procedure. Additionally, there is no surgical history 
documented of a previous rotator cuff repair. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 total shoulder replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total shoulder replacement (23472).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator (K1019), provided on January 
19, 2023. 
 
You asked the Plan to pay for the Cala Trio nerve stimulator. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this device is considered experimental.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Where electric nerve stimulation is employed to treat motor function disorders, no 
reimbursement may be made for the stimulator or for the services related to its implantation since this treatment 
cannot be considered reasonable and necessary. 
 
We looked the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the Cala Trio nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cala Trio nerve stimulator (K1019), provided on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; sacral nerve (transforaminal placement) including image guidance, if performed (64561), and insertion 
or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 
(64590). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array; sacral nerve 
(transforaminal placement) including image guidance, if performed, and insertion or replacement of peripheral 
or gastric neurostimulator pulse generator or receiver, direct or inductive coupling. You say that this is 
medically necessary. The Plan denied your request. The Plan says there is no documentation of a voiding diary 
showing that the trial electrodes improved symptoms by 50% or more. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation can be covered under certain 
conditions. 
 
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 percutaneous implantation of 
neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if 
performed, and insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, 
direct or inductive coupling. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the provided records in this case do not document through voiding diaries a 50% or greater 
improvement in symptoms through test stimulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array; sacral nerve 
(transforaminal placement) including image guidance, if performed, and insertion or replacement of peripheral 
or gastric neurostimulator pulse generator or receiver, direct or inductive coupling have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator 
electrode array; sacral nerve (transforaminal placement) including image guidance, if performed (64561), and 
insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive 
coupling (64590).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 97026). 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says the acupuncture was provided by an unqualified provider. 
 
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, the acupuncture was provided by an unqualified 
provider. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810, 97811, 
97026).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 provided on April 
13, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. 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 pay for procedure codes 96365, 96366, and 96521 
provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth - completely bony 
(D7240). 
 
You asked the Plan to pre-approve the removal of an impacted tooth. You say that you called the plan prior to 
your mother's dental appointment informing them the tooth was going to be pulled. You also say that you were 
informed this service would be covered. The Plan denied your request. The Plan says extractions are covered 
within the enrollee's plan under specific codes on page 136 of the EOC. Code D7240 is not listed as a covered 
dental code and is therefore excluded from coverage. 
 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 the 
removal of an impacted tooth - completely bony (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, intraoral x-
ray, and limited oral evaluation (D0364, D0220, D0140) provided on May 15, 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. Coverage for the cone beam CT scan 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. Coverage for 
the cone beam CT scan denied correctly as they do not fall within your dental benefits. Additionally, the record 
shows your benefit for the requested item or service was exhausted on date of service March 14, 2023. 
Therefore, we decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, 
intraoral x-ray, and limited oral evaluation (D0364, D0220, D0140) provided on May 15, 2023.