Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services (G0299, G0300). 
 You asked the Plan to pre-approve home health services. You say that the services are not medically necessary.  
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that the enrollee requires additional skilled nursing services to provide treatment that is medically 
necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, 
care, and/or services in order to improve the enrollees condition, perform a maintenance program to maintain 
the enrollees condition and/or prevent deterioration. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services (G0299, G0300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3310) for tooth #11, an 
apicoectomy (D3421 and D3410) for tooth #5 and #6, and a retrograde filling (D3430) for tooth #5 and #6.  
 
You asked the Plan to pre-approve the dental services. You say that you were referred to the oral surgeon and 
the dental services are medically necessary, and you will lose some of the bone in your check if they are not 
done. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the endodontic therapy, an apicoectomy, and a retrograde filling 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. 
 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 
endodontic therapy (D3310) for tooth #11, an apicoectomy (D3421 and D3410) for tooth #5 and #6, and a 
retrograde filling (D3430) for tooth #5 and #6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Vertiflex device. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the Vertiflex Superion interspinous 
spacer at L4-5, in this case, is not medically reasonable or 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on April 19, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that the provider called and spoke with a 
Plan representative to verify any available help toward purchase. You also say the provider was given 
information that $500 was available, with no mention that it had to be purchased through a certain company. 
The Plan denied your request. The Plan says hearing aids must be purchased through the Plan hearing. 
 
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 the hearing aids are obtained through an in-network Plan hearing provider.  
 
 
  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 (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia  first 15 minutes 
(D9222) provided on June 23, 2023. 
 
You asked the Plan to pay for the deep sedation/general anesthesia. You say that you are appealing the denial 
of payment for sedation during a dental extraction as you feel it should be paid. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep 
sedation/general anesthesia  first 15 minutes (D9222) provided on June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc NP procedure (0627T, 0628T). 
 
You asked the Plan to pre-approve a Via Disc NP procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Via Disc NP procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found via disc NP is experimental for back pain. 
 
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 Via Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Via Disc NP procedure (0627T, 0628T).
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).  
You asked the Plan to pre-approve a CGM. You say that you need this CGM. The Plan denied your request. 
The Plan says the medical criteria for a CGM have not been 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 use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for hernia repair to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve inpatient admission to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient admission for hernia repair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulp cap (D3110) and the clinical crown lengthening 
(D4249). 
 
You asked the Plan to pre-approve the dental services. You say that the crown extension is required for the 
crown to be seated properly and you would like the Plan to cover the cost. The Plan denied your request. The 
Plan says the denial of authorization for these services is correct, because the pulp cap and the clinical crown 
lengthening 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. 
 
  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 
pulp cap (D3110) and the clinical crown lengthening (D4249).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional miles for a total of 70 miles for a one-way 
trip. 
 
You asked the Plan to pre-approve 20 additional miles for a total of 70 miles for a one-way trip. You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says each one-way trip must 
not exceed 50 miles of driving distance. 
 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 24 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 mileage. Therefore, 
we decided that the Plan does not have to pre-approve 20 additional miles for a total of 70 miles for a one-way 
trip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial flexible base denture (D5225). 
 
You asked the Plan to pre-approve D5225. You say that you would like the Plan to approve this denture. The 
Plan denied your request. The Plan says the requested denture 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial flexible base denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool.  
 
You asked the Plan to pre-approve a tub stool. You say that you believe that you need the chair because you 
have difficulty standing in the shower. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that tub stools are not covered because they are not 
primarily medical in nature.  
 
While a tub stool may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a tub stool.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala Trio therapy system (K1018). 
 
You asked the Plan to pre-approve Cala Trio therapy system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Cala Trio therapy system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that this device is effective for the 
enrollee's tremor. The requested K1018 is not the standard of care for this enrollee's tremor according to current 
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 Cala Trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cala Trio therapy system (K1018).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee would benefit with this shower 
chair. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92507 provided on September 21, 2023. 
 
You asked the Plan to pay for procedure code 92507. 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the ICD-10-CM Coding Guidelines.  
 
We looked at the file and Medicare rules. The file shows that billed diagnosis codes, R13.12, I69.354, and 
I50.9 are not included on the list of covered diagnosis codes for procedure code 95907. Based on this 
information, we decided that Medicare rules for coverage of procedure code 92507 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 92507 provided on September 21, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement. 
 
You asked the Plan to pre-approve a total knee replacement. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 knee replacement. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested total knee replacement is 
not medically reasonable or 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 a total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retreatment of a root canal (D3347) for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee has an infected tooth, and the 
requested dental service is necessary the provider cannot fix the crown while there is an infection. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the 
retreatment of a root canal 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
retreatment of a root canal (D3347) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified implant procedure (D6199). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified implant procedure (D6199).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,200 annual maximum 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 $2,200 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) for tooth #4, the deep sedation (D9222 
and D9223), a consultation (D9310), and the therapeutic drugs (D9612) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you verified prior to the date of service that the 
dental services would be covered at 100%. The Plan denied your request. The Plan says your dental maximum 
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 $1,000 for dental services on June 28, 2023; therefore, your annual maximum benefit for 
the year of 2023 was exhausted on the date of service of June 28, 2023. Therefore, we decided that the Plan 
does not have to pay for an extraction (D7140) for tooth #4, the deep sedation (D9222 and D9223), a 
consultation (D9310), and the therapeutic drugs (D9612) provided on June 28, 2023.