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

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that you were advised that crowns would be 
covered by the Plan. The Plan denied your request. The Plan says the denial of authorization for these services 
is correct, because the specific requested crowns 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 
crown (D2751) for tooth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are scheduled to have a total 
hip replacement. You also say that you have a history of blood clots in both calves. The Plan denied your 
request. The Plan says this service is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized 
and will require multi-disciplinary approach for an extended period of time. The Plan denied your request. The 
Plan says the enrollee is medically stable and no longer requires an acute level of care, ongoing needs for 
skilled therapy, respiratory therapy, and skilled nursing may be completed in a lower level of care. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0018U, 0245U and 88381 provided on May 
25, 2023. 
 
You asked the Plan to pay for procedure codes 0018U, 0245U, and 88381. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 0018U, 0245U, and 88381 are not supported in the medical record. Specifically, the 
records do not support that a specimen was collected for the billed date of service. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 0018U, 0245U, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 0018U, 0245U and 88381 
provided on May 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found this enrollee was diagnosed with 
obstructive sleep apnea in 2003 and has been on CPAP. The enrollee is requesting a new device. The enrollee's 
sleep apnea symptoms were not completely controlled on the enrollee's device. The enrollee had diagnostic 
polysomnography on July 25, 2023, that confirmed mild obstructive sleep apnea. There is no device download 
to assess compliance and adequacy of treatment. It would be reasonable to provide the enrollee with an auto 
titrating CPAP and then assess compliance and adequacy of treatment of the sleep disordered breathing from a 
device download. An attended PAP titration study would be necessary only if the auto titrating CPAP was 
unsuccessful in treating the sleep disordered breathing. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will receive daily physician 
visits, daily labs and daily wound care and be able to successfully wean off ventilator. The enrollee's complex 
needs can only be met in an LTACH. The Plan denied your request. The Plan says the enrollee's records do not 
show documentation of three or more trials to be able to breathe on own. The Plan said the enrollee can receive 
the care needed in the current acute care setting. 
 
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 is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment simulation using 3D image volume 
(D0393), the guided tissue regeneration (D4266), the bone replacement graft (D7950), and the therapeutic 
parenteral drugs (D9612) for tooth #7 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the treatment simulation using 3D image volume, the guided tissue regeneration, the bone replacement 
graft, and the therapeutic parenteral drugs 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 
treatment simulation using 3D image volume (D0393), the guided tissue regeneration (D4266), the bone 
replacement graft (D7950), and the therapeutic parenteral drugs (D9612) for tooth #7 and #10.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve TP53 genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that the enrollee has chronic lymphocytic 
leukemia. The Plan denied your request. The Plan says that the test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 requested testing. Our physician 
reviewer found that the enrollee was seen for lymphocytosis and is being worked up for B-cell 
leukemia/lymphoma and Chronic lymphocytic leukemia. The work-up showed findings consistent with mild 
chronic lymphocytic leukemia. The requested testing is supported in medical journals. TP53 testing is indicated 
in the work-up of chronic lymphocytic leukemia. The testing is medically reasonable, indicated and necessary 
in this case for diagnostic purposes and treatment decision making process.  
 
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 requested testing have been met. Therefore, we decided that the Plan has to 
pre-approve TP53 genetic testing.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on June 
25, 2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that you were treated in your 
home and declined transportation. The Plan denied your request. The Plan says the ambulance benefit is a 
transport benefit, if no transport occurs then there is no Medicare covered service. 
 
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 June 25, 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 services without transport received 
on June 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 7, 2022. 
 You asked the Plan to pay for the ambulance services. You say that the claim is not hospice related. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on September 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. Testing to diagnose obstructive sleep apnea can be 
safely provide with a home sleep apnea test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found this enrollee has symptoms suggestive of 
obstructive sleep apnea. There is no contraindication to a home sleep study. The enrollee does not have severe 
heart or lung disease, symptoms suggestive of parasomnias or narcolepsy, a seizure disorder, or a BMI greater 
than 45. A home sleep study would be a reasonable initial approach. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99350 billed for date of service June 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the denial conflicts with the Plan's 
reimbursement policies. The Plan denied your request. The Plan says that code G0318 is included in procedure 
code 99350. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code 99350 is home or residence visit for the evaluation and 
management of an established patient. The definition of code G0318 is prolonged home or residence evaluation 
and management service(s) beyond the total time for the primary service (list separately in addition to CPT 
codes 99345, 99350 for home or residence evaluation and management services).   
 
We find that CPT code 99350 is supported. The claim information shows that add-on code G0318 was paid by 
the Plan. As the add-on code has been paid, the primary procedure code, 99350, is payable in this case. 
Furthermore, there are no code edits for this code pair that excludes separate payment. Based on this 
information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan 
has to pay for procedure code 99350 billed for date of service June 16, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says you have 
used your 24 one-way transportation trips and the benefit has been exhausted. 
 
 
 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 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approved 
additional routine transportation trips. 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 (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided on June 12, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had your last full set of x-rays performed by 
the provider in which you were unhappy with. You also say that you  switched dentists and as a new patient, 
they required a new set of full x-rays. The Plan denied your request. The Plan says your benefit for the 
requested 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 service was exhausted on date of service April 13, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) 
provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on June 07, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visit. 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 hospital outpatient clinic 
visit provided on June 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120) provided on May 
3, 2023. 
 
You asked the Plan to pay for the complete mandibular denture. You say that you received a partial denture in 
2019 and cancer decayed the root of your teeth which resulted in all of your teeth being pulled. You also say 
that you have been eating on your gums for over 3 years. The Plan denied your request. The Plan says your 
benefit for the complete mandibular denture 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 complete mandibular denture was exhausted on date of service July 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete denture - mandibular (D5120) 
provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry (92136) and a specialist office visit 
(99204) provided on June 13, 2023. 
 
You asked the Plan to pay for ophthalmic biometry (92136) and a specialist office visit (99204). You say that 
this claim was denied for no referral on file for this date of service. 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 ophthalmic biometry 
(92136) and a specialist office visit (99204) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the maxillary and mandibular complete dentures. You say that you never 
used the set you received on October 21, 2021. You also say that they were in bad condition and you could not 
eat with them. The Plan denied your request. The Plan says your benefit for the maxillary and mandibular 
complete dentures 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 service was exhausted on date of service October 21, 2021. Therefore, we 
decided that the Plan does not have to pre-approve the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on April 03, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that this was the nearest facility for the enrollee to seek stabilization for their addiction distress. 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 medication assisted 
treatment, and a take home supply of methadone provided on April 03, 2023.