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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing upper right and lower 
right quadrants of the mouth (D4341) provided on April 6, 2023. 
 
You asked the Plan to pay for periodontal scaling and root planing. 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 
periodontal scaling and root planing upper right and lower right quadrants of the mouth (D4341) provided on 
April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour Next Gen blood glucose meter and test strips. 
 
You asked the Plan to pre-approve the blood glucose meter and test strips. You say that the requested blood 
glucose meter is medically necessary for the enrollee. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose meter and test strips. Therefore, we decided that the Plan does not have to pre-approve a 
Contour Next Gen blood glucose meter and test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the L1 kyphoplasty. You say that you have a fractured spine and your 
doctor informed you that physical therapy is not done with this type of fracture.  The Plan denied your request. 
The Plan says the L1 kyphoplasty is not medically necessary. The Plan says there is documentation of bone 
repulsion which encroaches on the ventral dural sac, additional pathology noted on the magnetic resonance 
imaging (MRI), and no documentation of trial and failure of conservative treatment.  
 
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 L1 kyphoplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is fracture retropulsion which is a contraindication to kyphoplasty. 
 
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 L1 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the L1 kyphoplasty (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services by an OON provider.  
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says in-network providers are 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 
LTACH services by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services.  
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says dental services from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the dental 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cervical decompression and fusion for cervical spine 
surgery. 
 
You asked the Plan to pre-approve the cervical decompression and fusion for cervical spine surgery. You say 
that the enrollee has persistent and severe pain and continued conservative treatment will not provide 
significant pain relief.  The Plan denied your request. The Plan says  the cervical decompression and fusion for 
cervical spine surgery 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 cervical decompression and fusion 
for cervical spine surgery. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee is a smoker, and there is no documentation of smoking cessation. Smoking is a contraindication to surgery. 
 
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 cervical decompression and fusion for cervical spine surgery have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the cervical decompression and fusion 
for cervical spine surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
he Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayments for an in-network diagnostic ultrasound 
provided from January 10, 2023, to March 27, 2023. 
 
You asked the Plan to lower the copayments for an in-network diagnostic ultrasound. You say that you should 
not have to pay this large copayment, you had a nurse check the ultrasounds both times, not a doctor.  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 $150 
copayment for other outpatient diagnostic tests.  
 
You have been asked to pay a $300 total copayment for an in-network diagnostic ultrasound ($150 x 2 visits = 
$300). This item/service falls within the other outpatient diagnostic tests 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 lower the copayments for an in-network diagnostic ultrasound provided from January 
10, 2023, to March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compression device. You say that this is medically necessary, 
and needs to be covered. The Plan denied your request. The Plan says there are other providers available who 
are in-network, who are within the Medicare allowable distance from your residence. 
 
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 
pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.  
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
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 requested compression 
stockings are medically necessary for your medical problems. The Plan denied your request. The Plan says the 
requested compression stocking is non-covered under the surgical dressing benefit. 
 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 for additional non-emergent medical transportation. 
 
You asked the Plan to pre-approve for additional non-emergent medical transportation. You say that you do not 
have a car or transportation, you are disabled, and you need transportation to your doctors' appointments. The 
Plan denied your request. The Plan says per your EOC, you are covered for up to 24 one-way rides per year to 
get routine (non-emergency) medical care. 
 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 up to 24 one-way rides per year trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve for additional non-emergent medical transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to approve 48 additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you have no other means of transportation. The 
Plan denied your request. The Plan says the request exceeds the benefit limit. 
 
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 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 47 of 
the 48 total one-way routine transportation trips allowed by your supplemental benefit. Once you have used all 
48 one-way trips, further trips are not covered by the supplemental benefit or Medicare. Therefore, we decided 
that the Plan does not have to approve 48 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a limited oral evaluation (D0140). 
 
You asked the Plan to pre-approve the dental service. You say that you went to the dentist to get dentures and 
you are trying to avoid unnecessary billing. The Plan denied your request. The Plan says that your benefit for 
the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Specifically, the Plans has not substantiated their denial of the limited oral evaluation. 
Documentation shows that the last time a limited oral evaluation was covered was on the date of service of 
February 7, 2020, which is more than 1 year prior to the authorization request. Therefore, we decided that the 
Plan has to pre-approve a limited oral evaluation (D0140).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750).  
 
You asked the Plan to pre-approve the crown. You say that the crown that was put in was hurting so bad that 
you went back after 3 weeks and were told that there is nothing that they could do. The Plan denied your 
request. The Plan says your benefit for the crown - porcelain fused to high noble metal  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 July 29, 2020. Therefore, we 
decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that that without the requested equipment the 
enrollee is placed into dangerous health emergencies. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found that the enrollee has COPD 
and obstructive sleep apnea with chronic respiratory failure. The enrollee was also admitted to the hospital with 
hypercapnic respiratory failure and had improved with BiPAP therapy. This is not considered a BIPAP failure. 
Therefore, the request does not meet the requirements stated for a home ventilator based on the documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381) for teeth numbers 1, 4 to 17, 20 to 
29, and 31. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist requested you receive gum 
medication applied to several areas in your gums to prevent tooth loosening. 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 on date of service July 19, 2023. Therefore, 
we decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381) for teeth numbers 1, 4 to 17, 20 to 
29, and 31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an establishing appointment along with follow ups to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an establishing appointment along with follow ups. You say that this is 
medically necessary and should be covered. The Plan denied your request. The Plan says there are other 
providers available who are in-network, who are within the Medicare allowable distance from your residence. 
 
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 
an establishing appointment along with follow ups to be provided by an out-of-network (OON) provider.