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

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) provided on March 15, 2023. 
 
You asked the Plan to pay for the dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 item provided was exhausted on date of service July 20, 2021.   
 
 
 
 
Specifically, the Plans contract states that a prefabricated post and core in addition to a crown is covered once 
every 60 months. You previously received a core buildup (D2950) on July 20, 2021, less than 60 months prior, 
which was paid for by the Plan. A core buildup is an associated dental item within the same category of 
benefits. Therefore, you have exhausted the allowable benefit for the dental item provided in this case. 
Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a 
crown (D2954) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 18, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. There is no network deficiency for these services and alternate 
network providers were found. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that due to the extreme pain you have 
been experiencing you need long-term pain relief. The Plan denied your request. The Plan says the 
radiofrequency ablation is not medically necessary.  
 
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 the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
you have right sacroiliitis and has tried chiropractic and physical therapy. Also, you take Tramadol and has had 
two right sacroiliac joint injections with significant relief. However, the radiofrequency ablation is considered 
experiential due to the wide variation in efficacy reported in the literature.  
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or receiver, 
supplies and accessories. 
 
You asked the Plan to pre-approve the CGM or receiver, supplies and accessories. You say that you have been 
using a CGM for the last 3 or more years and had been approved by Medicare previously. The Plan denied your 
request. The Plan says the clinical notes from your provider do not indicate that you are treated with insulin or 
have concerns with hypoglycemia. 
 
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 the CGM or receiver, supplies and 
accessories. Our reviewer says that the CGM, supplies and accessories are not medically necessary. Our 
physician reviewer found coverage criteria for CGM require low blood glucose sugar or insulin use. You are 
not having low blood glucose sugar levels and are not on a medication that would cause low blood sugar. There 
is also no documentation of insulin use. We are also not told why a fingerstick monitoring would not suffice for 
your glucose monitoring at this time. So although the CGM might help you to control blood glucose sugar, 
criteria for coverage for CGM are not met.  
 
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 CGM or receiver, supplies and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or receiver, supplies 
and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that authorization is not required for this service. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on March 6, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 11, 2023.  
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says the number of definitive 
urine drug classes requested are not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
enrollee did not have an indication for definitive urine toxicology. The testing was not medically reasonable 
and 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 the definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
October 21, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the rendered device. 
 
The Plan follows Medicare rules. The rules 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 October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular lens 
(V2787). 
 
You asked the Plan to pre-approve astigmatism correcting function of intraocular lens (V2787). You say that 
these lenses were recommended by the provider to get acceptable vision. The Plan denied your request. The 
Plan says Medicare allows coverage of a "standard" intraocular lens to replace the natural lens after cataract 
surgery. The Plan also says therefore the request is denied. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL. 
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve astigmatism 
correcting function of intraocular lens (V2787).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 for date of service November 10, 
2022. 
 
You asked the Plan to pay for procedure code 87631. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87631 for date 
of service November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body, custom fabricated 
abutment, and an abutment supported porcelain/ceramic crown (D6058, D6057, D6011). 
 
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 
surgical access to an implant body, custom fabricated abutment, and an abutment supported porcelain/ceramic 
crown (D6058, D6057, D6011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that the requested supply 
allowance is medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
 
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 the supply allowance for the CGM. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the CGM 
coverage criteria requires insulin use or low blood sugars. This enrollee is not using insulin and is not having 
low blood sugars that we are told of. In addition, Janumet usually does not cause symptomatic low blood 
sugars and we are also not told why fingerstick glucometer would not suffice for this enrollee at this time. 
Although a CGM may help the enrollee regulate their blood sugars, the 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 the supply allowance for the CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for codes E2201, E2204, E2231, K0040, E0951, E2211, E0961, E0973, 
E0978, E2607, E2620, and E0971 for date of service December 26, 2022. 
 
You asked the Plan to pay for codes E2201, E2204, E2231, K0040, E0951, E2211, E0961, E0973, E0978, 
E2607, E2620, and E0971. You say that only two months of rental payments were received. The Plan denied 
your request. The Plan says that we previously paid this claim at the purchase price. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that they previously paid this claim 
at the purchase price. The documentation does not explain what exactly was paid and this cannot be paid as 
billed. No Medicare rule was provided to support this denial. No other denial rationale was provided. The Plan 
did not substantiate their denial. Therefore, we decided that the Plan has to pay for codes E2201, E2204, 
E2231, K0040, E0951, E2211, E0961, E0973, E0978, E2607, E2620, and E0971 for date of service December 
26, 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: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) and the full mouth debridement (D4355) provided on April 4, 2023. 
 
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 a full mouth debridement is not a covered 
benefit under the supplemental dental policy. Additionally, you have exhausted the allowable benefit for the 
intraoral-periapical additional radiographic image provided.  
 
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 full mouth debridement provided is 
not among those covered under this benefit. Additionally, the Plans contract states that one intraoral- 
periapical radiographic image is covered per year. On this day, you received two intraoral-periapical x-rays in 
which one was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to pay for the intraoral-periapical additional radiographic 
image (D0230) and the full mouth debridement (D4355) provided on April 4, 2023.
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-
rays, and a prefabricated post and core in addition to crown (D2954, D0367, D0220, D0230 x5) provided on 
March 13, 2023, to March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the intraoral x-rays has already 
been exhausted.  Additionally, this benefit does not include cone beam CT Scans or prefabricated post and core 
in addition to crowns. 
 
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 on date of service January 10, 2023 
(D0220, D0230 x5). Additionally, this benefit does not include cone beam CT scans or prefabricated post and 
core in addition to crowns. Therefore, we decided that the Plan does not have to pay for a cone beam computed 
tomography (CT) scan, intraoral x-rays, and a prefabricated post and core in addition to crown (D2954, D0367, 
D0220, D0230 x5) provided on March 13, 2023, to March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state provided on April 28, 
2023.  
You asked the Plan to pay for the vision service. You say that this provider is in the Plan's system. The Plan 
denied your request. The Plan says the service was correctly denied. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed with a routine exam. 
 
We looked at the file and the Plan's rules. Determination of refractive state is covered when performed with a 
routine exam. Based on this information, we decided that the Plan's rules for coverage of the vision service 
have not been met. Specifically, the record indicates that you were seen for a medical exam, not routine. 
Additionally, the provider does not participate with the Plan's vision benefit. Therefore, we decided that the 
Plan does not have to pay for the determination of refractive state provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve 9 additional office visits. You say that you have seen this enrollee since 
2019 as an out-of-network provider. You also say that the enrollee does not want to change providers.  The 
Plan denied your request. The Plan says the services can be provided in-network. 
 
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 confirmed there are 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Additionally, there were no recent medical records 
provided to indicate that the services are medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve 12 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the short-latency somatosensory evoked potential study (95938), and 
continuous intraoperative neurophysiology monitoring (G0453) provided on February 14, 2023. 
 
You asked the Plan to pay for the intraoperative monitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not indicated the rules that were used to deny these services. 
Therefore, we decided that the Plan has to pay for the short-latency somatosensory evoked potential study 
(95938), and continuous intraoperative neurophysiology monitoring (G0453) provided on February 14, 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.