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

 
We decided that the Plan does not have to pay for cataract surgery (66984) and anesthesia for procedures on 
eye (00142) provided from March 8, 2022, to March 29, 2022. 
 
You asked the Plan to pay for cataract surgery (66984) and anesthesia for procedures on eye (00142). You say 
that you have been responsible for all of your medical bills since January 2022 up until November 2022 
because your other insurance told you that they were primary. The Plan denied your request. The Plan says that 
the insurance that pays first is called the primary payer and pays up to the limits of its coverage. The one that 
pays second, called the secondary payer, only pays if there are costs left uncovered by the primary coverage. 
The Plan also says that they are the secondary payer on this date of service. 
 
  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has shown that 
they directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be 
held responsible for cataract surgery (66984) and anesthesia for procedures on eye (00142) until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for 
cataract surgery (66984) and anesthesia for procedures on eye (00142) provided from March 8, 2022, to March 
29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an incomplete endodontic 
therapy (D3332), intraoral imaging (D0220), and extractions (D7210), provided February 7, 2023. 
 
You asked the Plan to pay for D0140, D3332, D0220, and D7210. You say that these services should be 
covered by the Plan. The Plan denied your request. The Plan says the rendered dental services are not covered 
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 enrollee is not enrolled in a supplemental dental plan. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an incomplete endodontic 
therapy (D3332), intraoral imaging (D0220), and extractions (D7210), provided February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220/D0230) provided on March 7, 
2023. 
 
You asked the Plan to pay for intraoral imaging. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the denied services are not covered 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 intraoral 
imaging (D0220/D0230) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided March 31, 2022, to November 10, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you could not get an appointment until March. 
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 dental services provided March 31, 2022, to November 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyvgart. 
 You asked the Plan to pre-approve Vyvgart. 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. 
 
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 Vyvgart. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is documentation of a trial of Cellcept (mycophenolate) but there is no indication that the enrollee has 
tried and failed one of the other required drugs. There is no indication that the plan's required drugs 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 Vyvgart have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vyvgart.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 provided on April 19, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99291 based Medicare criteria. Therefore, we decided that the Plan has to pay for 
procedure code 99291 provided on April 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right genicular 
nerves (64624). 
 
You asked the Plan to pre-approve RFA of the right genicular nerves. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 RFA of the right genicular nerves. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is the subject of ongoing clinical trials. It is considered 
experimental at this time. Therefore, the request is deemed 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 RFA of the right genicular nerves have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right genicular nerves (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM 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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars; the enrollee is not taking insulin. If there is a reason why this enrollee 
cannot use a fingerstick meter or is incapable of using one, this should be so stated in English and then 
submitted for re-review. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM 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 CGM and related supplies. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM requires insulin use or low blood sugars. This enrollee has neither documented; we are told 
the enrollee wants a CGM but are not told why a fingerstick meter would not suffice; the enrollee's A1c is a 7.3 
in May of 2023. The enrollees body mass index is 34.4. Although a CGM might help the enrollee, 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 CGM and related supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with field of view 
of both jaws; with or without cranium (D0367) provided on December 14, 2022. 
 
You asked the Plan to pay for the cone beam CT capture. You say that the provider informed you that the 
service would be covered by your insurance. You also say that had you know it would not be covered you 
would not have agreed. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
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 cone 
beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided 
on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse a continuous positive airway pressure (CPAP) mask 
purchased on April 6, 2023. 
 
You asked the Plan to reimburse a CPAP mask. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says you have no out-of-network benefits. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to reimburse a continuous positive airway pressure (CPAP) mask 
purchased on April 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (93041) provided on February 16, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 93041 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1 and was billed on the same claim as code 99285 with a status indicator of "V". Code 93041 is 
included in the Emergency Room service. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (93041) provided on February 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065). 
 
You asked the Plan to pre-approve a breath hydrogen or methane test. The Plan denied your request. The Plan 
says this test is not covered for diagnosing small intestinal bacterial overgrowth. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. 
 
We looked at the file and Medicare rules. Specifically, the record shows that this test was request for small 
intestinal bacterial overgrowth. Based on this information, we decided that Medicare rules for coverage of a 
breath hydrogen or methane test have not been met. Therefore, we decided that the Plan does not have to pre-
approve a breath hydrogen or methane test (91065).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reaching/grabbing device. 
 
You asked the Plan to pre-approve reaching/grabbing device. You say that you would like reconsideration 
because the requested reaching/grabbing device is medically necessary. The Plan denied your request. The Plan 
says the requested reaching/grabbing device is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve reaching/grabbing device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the upper 
extremity. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show six weeks of provider treatment has been 
completed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the detailed documentation regarding a trial 
and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. 
Additionally, there are no provided x-rays that are non-diagnostic. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the upper extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are unable to access care/benefits. The 
Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 1, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was an 
emergent situation, and you had to call ambulance to make sure the enrollee was alright. You also say that the 
enrollee fell off a fairly high stool, cracked their head, was bleeding, and you were concerned that they had a 
concussion. The Plan denied your request. The Plan says these services are not a covered benefit because an 
ambulance is a transport benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 The ambulance company did not provide transport services on March 1, 2023. The additional information sent 
in by the enrollee shows that they decided to refuse transportation. The ambulance benefit is a transportation 
benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we 
decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) 
provided on March 1, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport and 
ground mileage provided on March 6, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee had two 
separate transports on the date of service. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan denied payment for this service 
on the basis that it is a duplicate of another claim that was already paid. However, the other claim the Plan 
submitted is for a separate ambulance trip and was billed with the appropriate modifiers to distinguish it from 
the service at issue in this case. The Plan did not submit any other evidence of a duplicate claim. Based on this 
information, we decided that Medicare rules for coverage of the ambulance service and ground mileage have 
been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, 
emergency transport and ground mileage provided on March 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 27, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
March 27, 2023.