Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle 3 Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle 3 Libre 3 sensor. You say that you are recommending the 
FreeStyle Libre sensor as the enrollee tests her glucose 3 or more times a day and has a recent HgbA1C of 
7.9%. The Plan denied your request. The Plan says the information received and reviewed shows that the 
enrollee is not on insulin, does not have problematic hypoglycemia and is able to use a traditional glucose 
monitor 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle 3 Libre 3 sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy visit provided on January 4, 2023. 
 
You asked the Plan to pay for physical therapy. You say that your therapist was on vacation, so you had to see 
someone else, so you should not have to pay. The Plan denied your request. The Plan says the provider was not 
enrolled in Medicare at the time of services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the physical therapy visit provided on 
January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for trifocal lenses (V2303), photochromatic tint (V2744), anti-
reflective coating (V2750), and polycarbonate lenses (V2784) purchased on January 18, 2023. 
 
You asked the Plan to pay for trifocal lenses (V2303), photochromatic tint (V2744), anti-reflective coating 
(V2750), and polycarbonate lenses (V2784). You say that your prescribed lenses are necessary as you have 
double vision. You also say that you do not understand what exceeded the allotted stipend for routine vision 
benefit means. The Plan denied your request. The Plan says they paid $235, which is the allowed stipend 
amount for the purchases of glasses, and the balance of $526 was denied to the member as the benefit 
maximum has been reached. 
 
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 up to $235 toward the purchase of eyeglasses from a network provider for your 
routine vision and correction needs. 
 
We looked at the file and the Plan's rules. The Plan rules say that they will cover up to $235 toward the 
purchase of eyeglasses from a network provider for your routine vision and correction needs. The record shows 
the benefit was exhausted with this service. Based on this information, we decided that the Plan's rules for 
coverage of trifocal lenses (V2303), photochromatic tint (V2744), anti-reflective coating (V2750), and 
polycarbonate lenses (V2784)  have not been met. Therefore, we decided that the Plan does not have to pay for 
trifocal lenses (V2303), photochromatic tint (V2744), anti-reflective coating (V2750), and polycarbonate lenses 
(V2784) purchased on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for soft tissue dental grafts (D4278, D4277) provided on March 
15, 2023. 
 
You asked the Plan to pay for soft tissue dental grafts. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 soft tissue 
dental grafts (D4278, D4277) provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown restoration services (D6059) provided on March 7, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 pay for crown 
restoration services (D6059) provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 21, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
March 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided on February 10, 
2023. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you say that you feel that this is 
copayment stacking. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $175 copayment for diagnostic testing. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan does not have 
to waive the copayment for diagnostic testing provided on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641 billed for date of service February 15, 
2023. 
 You asked the Plan to pay for procedure code 87641. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 87641 is bundled into payment for code 87801. 
 
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, we have confirmed that code 87641 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87641 billed for date of service February 15, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary for a procedure that the Plan covered, and they are not for a wound. The Plan denied your 
request. The Plan says the requested compression stockings are not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the refraction provided on March 8, 2022. 
 You asked the Plan to pre-approve the refraction. You say that you were overcharged from your refractive 
exam. You say you were told that you would be reimbursed and that the provider was in-network. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the refraction provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sialography (D0310) provided on February 23, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sialography 
(D0310) provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse for frames (V2020) and progressive lenses (V2781) 
purchased on February 14, 2023.  
 
You asked the Plan to reimburse for frames (V2020) and progressive lenses (V2781). You say that you got the 
provider's name from the network list. The Plan denied your request. The Plan says these services were 
performed by an out-of-network provider and were authorized by the Plan or an in-network provider. 
 
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 they are provided in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover up to $200 per year for eyeglasses 
and lenses. The Plan contract also says that reimbursements are not permissible for expenses incurred at out-of-
network providers or retailers. Based on this information, we decided that the Plan's rules for coverage of 
frames (V2020) and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does 
not have to reimburse for frames (V2020) and progressive lenses (V2781) purchased on February 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensive outpatient mental health services described by 
code S9480. 
 
You asked the Plan to pre-approve procedure code S9480. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9480 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9480 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9480 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensive outpatient mental health services described by code S9480.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by a 
chiropractor. 
 
You asked the Plan to pre-approve physical therapy services. You say that the enrollee is unable to perform 
activities of daily living without pain or restrictions and has tolerated treatment well. You say that this care is 
medically necessary. The Plan denied your request. The Plan says the only covered chiropractic service is 
manual manipulation of the spine to correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy services to be provided by a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for vision supplies or accessories (V2797) purchased on 
February 24, 2023.  
You asked the Plan to reimburse for vision supplies or accessories (V2797). You say that these glasses are the 
only glasses you have obtained in 2023. The Plan denied your request. The Plan says the benefit maximum for 
these services has been met. 
 
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 up to $50 for eyeglasses every 12 months. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $500 for eyeglasses every 
12 months. The record shows the Plan paid $409 on July 5, 2022. Therefore, this benefit was exhausted with 
the $91 reimbursement for February 24, 2023. Based on this information, we decided that the Plan's rules for 
coverage of vision supplies or accessories (V2797) have not been met. Therefore, we decided that the Plan does 
not have to reimburse for vision supplies or accessories (V2797) purchased on February 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet the coverage criteria for Injectafer. Our physician reviewer found the Plan requires a 
trial of drug Venofer (iron sucrose) before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug(s). Our reviewer also found that there is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on March 29, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. The Plan denied your 
request. The Plan says your benefit for the intraoral - complete series of radiographic images 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 intraoral - complete series of radiographic images was exhausted on date of service 
April 25, 2022. Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of 
radiographic images (D0210) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical applications of fluoride varnish (D1206 x 3), 
bitewing x-rays-four radiographic images (D0274), intraoral-periapical additional radiographic image (D0230), 
intraoral-periapical first radiographic image (D0220), gingival irrigation-per quadrant (D4921), periodic oral 
evaluations (D0120 x 3), dental cleanings (D1110 x 3), unspecified preventive procedure, by report (D1999), 
core buildup, including any pins when required (D2950), and the dental crowns-porcelain fuse to high noble 
metal (D2750 x 2) provided from February 26, 2020, through March 7, 2022. 
 
You asked the Plan to pay for these items/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 items/services provided are not 
payable as the claim was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
  
 
 
The record shows that a claim for these items/services was not filed until March 27, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the topical applications of fluoride varnish (D1206 x 3), bitewing 
x-rays-four radiographic images (D0274), intraoral-periapical additional radiographic image (D0230), 
intraoral-periapical first radiographic image (D0220), gingival irrigation-per quadrant (D4921), periodic oral 
evaluations (D0120 x 3), dental cleanings (D1110 x 3), unspecified preventive procedure, by report (D1999), 
core buildup, including any pins when required (D2950), and the dental crowns-porcelain fuse to high noble 
metal (D2750 x 2) provided from February 26, 2020, through March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablations. 
 
You asked the Plan to pre-approve the radiofrequency ablations. You say that the enrollee is starting physical 
therapy. The Plan denied your request. The Plan says the radiofrequency ablations are 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 ablations. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the 
enrollee has chronic low back pain. The enrollee has tried medications such as Flexeril, Hydrocodone, 
Percocet, and Lyrica. Also, the enrollee has had two sets of diagnostic medical branch blocks (MBBs) at 4 
levels. However, there is a utilization limit of two levels per session. Additionally, there are no extraordinary 
circumstance documented for a reason to exceed the two-level limit. Therefore, the request to perform two 
additional radiofrequency ablations is 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 radiofrequency ablations. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablations.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210), and a 
comprehensive oral evaluation (D0150), provided on March 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider was on a list of in-network 
providers. The Plan denied your request. The Plan says your dental maximum allowable benefit was already 
reached. 
 
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 March 17, 2023. The 
claim for the paid date of service, March 17, 2023, was processed prior to the claim for March 10, 2023. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210), 
and a comprehensive oral evaluation (D0150), provided on March 10, 2023.