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

 
We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement tooth 
#13 (D6057) and abutment supported porcelain/ceramic crown tooth #13 (D6058). 
 
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 custom fabricated abutment - includes placement tooth #13 (D6057) and abutment 
supported porcelain/ceramic crown tooth #13 (D6058).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of one component of total knee joint prosthesis. 
 
You asked the Plan to pre-approve revision of total knee arthroplasty. You say that these services are medically 
necessary. The Plan denied your request. The Plan says medical records were requested but never received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of revision of total knee arthroplasty have 
been met. Medical records were requested by the Plan on July 24, 2023, by fax and phone, and on June 25, 2023, by phone. Therefore, we decided that the Plan does not have to pre-approve revision of one component 
of total knee joint prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that a therapeutic CGM is medically necessary. 
The Plan denied your request. The Plan says you do not meet the criteria for a therapeutic CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve therapeutic CGM. Our reviewer says 
that you the request is not medically necessary. Our physician reviewer found that you are not using insulin 
and we are not told of low blood sugars (nor would we expect any on just metformin). Therefore, coverage 
criteria are not met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve therapeutic CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the exercise classes (S9451) provided from 
January 5, 2022, through December 5, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services at 
issue are not payable as they were rendered by an out-of-network provider.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the exercise classes provided in this 
case were rendered by an out-of-network provider. The fitness benefit includes coverage for fitness classes 
only when provided by the Plans select fitness vendor. Therefore, we decided that the Plan does not have to 
issue reimbursement for the exercise classes (S9451) provided from January 5, 2022, through December 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics provided on January 09, 
2023. 
 
You asked the Plan to waive the coinsurance for foot orthotics. You say that you should not be billed for the 
item. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for foot orthotics. This item/service falls within the prosthetic 
devices and related supplies 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. The total you owe is $31.07 ($155.33 allowed amount x 20% = $31.07). Therefore, we 
decided that the Plan does not have to waive the coinsurance for foot orthotics provided on January 09, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services (G2067, 90792, 
99215) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the outpatient mental health services. You say that this service is medically 
necessary. The Plan denied your request. The Plan says there is a network provider available. 
 
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 
outpatient mental health services (G2067, 90792, 99215) 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 surgical placement of implant body: endosteal implant 
tooth #8, #9 (D6010), deep sedation/general anesthesia - First 15 Minutes (D9222), deep sedation / general 
anesthesia - each subsequent 15 Minute Increment (D9223). 
 
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 placement of implant body: endosteal implant tooth #8, #9 (D6010), deep sedation/general anesthesia - First 15 Minutes (D9222), deep sedation / general anesthesia - each subsequent 15 
Minute Increment (D9223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 19, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37252, 37253, 37235, 75710) provided on 
January 16, 2023. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 37252, 37253, 37235, & 75710 is not supported in the medical record. Specifically, the 
procedure reports provided do not document the procedures billed were performed. Records do not show that 
procedure 75710 was a separate and distinct service. Based on this information, we decided that Medicare rules 
for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to 
pay for surgical services (37252, 37253, 37235, 75710) provided on January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says based on the records received, an IRF admission is not 
supported.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) and supplies provided on 
February 22, 2023. 
 
You asked the Plan to pay for continuous glucose monitor (CGM) and supplies. You say that you are appealing 
the claim payment denial. 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 continuous glucose 
monitor (CGM) and supplies provided on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from  
December 12, 2022, through December 19, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not payable as the claim 
must first be submitted and processed by the primary insurer.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has directed the provider to send the bill to the primary insurer. Therefore, we decided that 
the Plan has to pay for the acute inpatient psychiatric hospital care provided from December 12, 2022, through 
December 19, 2022.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the implant for tooth #4. We decided that the Plan does not have to 
pay for implants for teeth #'s 18, 19, 30 and 31.  
 
You asked the Plan to pay for an endosteal implant (D6010) for teeth #'s 4, 18, 19, 30 and 31.. You say that the 
services should be covered as you disagree with the denial. The Plan says that the services denied correctly as 
they do not fall within your dental benefits. 
 
We decided that the Plan has to pay for the implant for tooth #4.  
 
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 endosteal implants. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the implant for area #4 meets the 
criteria for coverage according to the plan. Areas # 18, 19, 30 and 31 do not meet the criteria for coverage for 
implants.  
 
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 endosteal implants have been met. Therefore, we decided that the Plan has 
to pay for the implant for tooth #4.  
 
We also decided that the Plan does not have to pay for implants for teeth #'s 18, 19, 30 and 31. 
 
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 implants for teeth #'s 18, 19, 30 and 31. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the implant for 
area #4 meets the criteria for coverage according to the plan.  Areas # 18, 19, 30 and 31 do not meet the criteria 
for coverage for implants.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implants for teeth #'s 18, 19, 30 and 31 have not been met. Therefore, we 
decided that the Plan does not have to pay for implants for teeth #'s 18, 19, 30 and 31. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) and a 
determination of refractive state (92015) provided on March 21, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004) and a determination of 
refractive state (92015). You say that you do not see the need for a copayment, as you only had an annual 
visual examination. 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 a $40 
copayment for physician services to diagnose and treat diseases and conditions of the eye. 
 
You have been asked to pay a $40 copayment for a medical eye examination (92004) and a determination of 
refractive state (92015). This item/service falls within the physician services to diagnose and treat diseases and conditions of the eye 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 copayment for a medical eye 
examination (92004) and a determination of refractive state (92015) provided on March 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on October 3, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were emergent. The 
Plan denied your request. The Plan says in order for a facility to receive reimbursement for a Medicare 
member, the facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation - per site (D7953) and 
deep sedation/general anesthesia  first 15 minutes (D9222) provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you say that you do not agree with the denial of 
payment for the services you received. The Plan denied your request. The Plan says these services are not 
covered under your 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. This benefit will only cover 
dental services in a hospital setting or from injury to natural teeth. Dental care, dental procedures, or supplies, 
like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices are not covered. 
 
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 limited 
oral evaluation - problem focused (D0140), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement 
graft for ridge preservation - per site (D7953) and deep sedation/general anesthesia  first 15 minutes (D9222) 
provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on December 19, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on December 19, 2022.