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

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator for nine months. 
 
You asked the Plan to pre-approve the continued use of a home ventilator for nine months. You say that it is 
medically necessary for the enrollee to continue the use of a home ventilator. 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 the continued use of a home ventilator 
for nine months. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
the enrollee has severe COPD and obstructive sleep apnea, as well as class III obesity. Arterial blood gases 
during hospitalization for exacerbation have been consistent with acute on chronic hypercarbic respiratory 
failure. The enrollee was prescribed a home ventilator in 2021. However, in October 2022 the enrollee 
requested to go back on CPAP because they could no longer afford the ventilator. Apparently, the enrollee 
currently remains on the ventilator, with 100% compliance. The records do not show that the enrollee has been 
tried on BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings 
that can be provided with BiPAP. 
 
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 continued use of a home ventilator for nine months have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continued use of a home ventilator for 
nine months.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 5, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 5, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 5, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 5, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 5, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 5, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 5, 
2023, forward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x9). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
not shown to require the number of home health physical therapy visits requested. The enrollee is not noted to 
have a specific illness or injury, for which physical therapy is medically necessary.  The enrollee has shown 
improvement with just a couple of treatments. The enrollee has an available and willing caregiver to provide 
assistance and supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x9).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve these dental services. You say that you were told it would be covered if you 
went to a in network provider. 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 pre-approve 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 4, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 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 January 4, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0364) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental service. You say that there are no scanning offices in your service 
are and you were told you should be allowed to go to another nearby facility. Also, you can receive the 
requested dental service from a contracted endodontist. 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 item or service is 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 a cone 
beam (D0364) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 02, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory services 
provided on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement teeth 
2,3,4,5,12,14,15 (D6057), abutment supported porcelain/ceramic crown teeth 2,3,4,5,12,14,15 (D6058) and 
pontic -porcelain/ceramic teeth 6,7,8,9,10,11 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you never agreed to the denture procedure. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement teeth 2,3,4,5,12,14,15 (D6057), 
abutment supported porcelain/ceramic crown teeth 2,3,4,5,12,14,15 (D6058) and pontic -porcelain/ceramic 
teeth 6,7,8,9,10,11 (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 02, 2022. 
 
You asked the Plan to pay for an office visit. You say that you say that you were unable to get authorization as 
the patient came in under critical condition. 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 an office visit provided 
on September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on Mary 5, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the enrollee was denied treatment so 
you should not be responsible for the resulting bill. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and 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. 
 
 
 
 The record shows you received the requested 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 pay for a limited oral evaluation - problem focused (D0140) provided on Mary 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85007 and 85008 billed for date of service 
April 25, 2023.   

You asked the Plan to pay for procedure codes 85007 and 85008. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 85007 and 
85008 is bundled into payment for code 85025. 
 
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 codes 
85007 and 85008 are column II codes to column I code 85025 with a modifier indicator of 0. The column II 
codes are therefore not payable. 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 codes 85007 and 85008 billed for date 
of service April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), periodontal 
maintenance (D4910), and bone replacement graft for ridge preservation - per site (D7953) provided on May 
18, 2023, and May 22, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and 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. 
 
 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested 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 pay for 
an extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210), periodontal maintenance (D4910), and bone replacement graft for 
ridge preservation - per site (D7953) provided on May 18, 2023, and May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for fruit and veggie supplements purchased on July 4, 
2023. 
 
You asked the Plan to reimburse for fruit and veggie supplements. You say that you called the Plan before you 
ordered this vitamin and were told that it would be accepted. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
 
  The items you asked the Plan to reimbursement for are considered nutritional supplements. Although these may 
be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to reimburse for fruit and veggie supplements purchased on July 4, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.  
You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 26, 2022. 
 
You asked the Plan to pay for an 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 an office visit provided 
on August 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neuromonitoring services (procedure codes 
G0453 and 95940) rendered on February 22, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not submitted with an appropriate diagnosis. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee underwent parathyroidectomy exploration, excision 
of adenoma, and total thyroidectomy.  The record indicates that remote monitoring was performed and the 
technologist was not present at the operating site recording and monitoring the events. The elements of the 
coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative neuromonitoring services (procedure codes G0453 and 95940) rendered on 
February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on June 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered because you 
had to have the procedure done before you can have the extraction. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the consultation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 26, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial upper denture (D5211) and a partial lower denture 
(D5212) provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentures were broken, and the provider 
told you that the new dentures would be covered by the Plan. The Plan denied your request. The Plan says your 
annual dental maximum benefit for the year 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 the Plan paid $110 for dental services on February 1, 2023. On February 7, 2023, the Plan paid $269 for 
dental services. On February 28, 2023, the Plan paid $121 for dental services. For the year of 2023 the Plan 
paid $500 ($110 paid + $269 paid + $121 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of February 28, 2023. Therefore, we decided 
that the Plan does not have to pay for a partial upper denture (D5211) and a partial lower denture (D5212) 
provided on April 10, 2023.