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

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment abutment supported 
porcelain implant (D6059, D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 because the plan has already approved 2 
implant services with an authorization period from May 2, 2023, to July 31, 2023. Therefore, we decided that 
the Plan does not have to pre-approve a custom fabricated abutment abutment supported porcelain implant 
(D6059, D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special service provided on February 21, 2023.  
You asked the Plan to pay for the special service. You say that you have been reimbursed every year for your 
prescription glasses. 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 this service when received in-network. 
 
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 special service have not been met. Therefore, 
we decided that the Plan does not have to pay for the special service provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000). 
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryosurgical ablation of the prostate (55873). 
 You asked the Plan to pre-approve the surgical procedure. You say that the enrollee is a candidate for definitive 
therapy whether that be radiation, surgery or ablative technique. Cryoablation would be your particular choice 
in this matter. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the Plan confirmed after outreach to the 
provider, that the enrollee has not had radiation and the PSA test is not below 8. Based on this information, we 
decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cryosurgical ablation of the prostate (55873).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on December 26, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you should be reimbursed $95 for 
the out-of-pocket payment you made for the eye exam. 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 $15 
copayment for each Medicare-covered exam.  
 
 You have been asked to pay a $15 copayment for the eye exam. This eye exam falls within vision care 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 the eye exam provided on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tree tea oil provided on June 21, 2022. 
 
You asked the Plan to pay for the tree tea oil. You say that the tea tree oil is a skin protectant and should 
qualify as a covered benefit. The Plan denied your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the tree tea 
oil is an OTC item. Therefore, we decided that the Plan does not have to pay for the tree tea oil provided on 
June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of a pacemaker (code 33207) billed for date of 
service November 9, 2022. 
 
You asked the Plan to pay for code 33207. You say that the medical records support the billing for this service. 
The Plan denied your request. The Plan says you did not bill this service with the required KX modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for cardiac pacemakers, the KX 
modifier must be used as an attestation by the provider that documentation on file verifying the patient meets 
coverage criteria for the item. Claims without the required modifier will be denied. You did not bill the 
pacemaker in dispute with the required KX modifier.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 33207 have not been met. Therefore, we decided that the Plan does not have to pay for the 
insertion of a pacemaker (code 33207) billed for date of service November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy (97803). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the enrollee has a diagnosis 
of anorexia nervosa, restricting type. Please consider covering further appointments with a nutritionist, as the 
enrollee works to manage this disease. The Plan denied your request. The Plan says the enrollee does not have 
a qualifying condition to qualify for the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve medical nutrition therapy (97803).
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 items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do 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 for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on January 17, 2023. 
 You asked the Plan to pay for the refraction. You say that you did not know there was a charge for the service 
performed on your eyes. You say you have not been charged in the past for the same service. 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 this service when performed as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed as a part of a routine 
eye exam. The medical records show a diagnosis of benign neoplasm of right choroid which makes the eye 
exam medical in nature. 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 pay for the refraction 
provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the warranty provided on February 14, 2023. 
 You asked the Plan to pay for the warranty. You say that you disagree with the denial and are requesting 
reconsideration. 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 does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not listed as a covered benefit. Based on 
this information, we decided that the Plan's rules for coverage of the warranty have not been met. Therefore, we 
decided that the Plan does not have to pay for the warranty provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient left L4-S1 radiofrequency ablations 
(RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that you are appealing the denial because 
you are in extreme pain and if you do not get the pain under control, it can cause other medical issues. The Plan 
denied your request. The Plan says under Medicare guidelines, the request 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 looked at the file, and Medicare rules. The rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. The records show that the enrollee has 
had 3 radiofrequency ablations sessions within the last 12 months. Based on this information, we decided that 
Medicare rules for coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient left L4-S1 radiofrequency ablations (RFA) (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that this claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 15, 2022, 
to January 13, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 15, 2022, to 
January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three trips with additional mileage 
 
You asked the Plan to pre-approve the two trips with additional mileage. You say that you have not been able 
to location new doctors closer to your home. You say you need transportation approved to go to your established doctors. The Plan denied your request. The Plan says trips over the mileage limit are not a covered 
benefit. 
 
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 60 miles per each one-way trip based on the most efficient route.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional mileage exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve three trips with additional mileage
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with high gold content crown (D2750) Tooth #8, 10, 
24, and 25 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says that you do not meet criteria for crowns. 
 
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. Specifically, the Plan did not send DIGITAL x-rays. You say that the requested 
services are needed. Without clear x-rays we are unable to determine if you meet criteria. Therefore, we 
decided that the Plan has to pre-approve white glass with high gold content crown (D2750) Tooth #8, 10, 24, 
and 25  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 3, 2022, billed 
with codes 87798, 87481, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting reconsideration of your 
appeal and approval of payment of the laboratory services provided. The Plan denied your request. The Plan 
says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 3, 2022, billed with codes 87798, 87481, and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MAKOplasty services during shoulder surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says studies 
haven't proven the use of the technique. 
 
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 requested services. Our physician 
reviewer found that MAKOplasty is not medically needed in right shoulder surgery. The literature does no 
show better outcomes when compared to traditional surgery. Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MAKOplasty services during shoulder surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26340 for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 26340. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code 26340 is manipulation, finger joint, under anesthesia, 
each joint. 

We find that CPT code 26340 is not supported in the medical record. Specifically, while this code was billed 
with modifier LT, the code was not billed with an additional modifier to indicate the digit. This additional 
modifier (FA, F1-F9, TA, T1- T9, E1-E4) to indicate the digit is required for code 26340. This code is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 
26340 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 26340 
for date of service June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit, the lab services, and the 
infusion therapy services provided on December 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the clinic visit, the lab services, and the infusion therapy services. You say that 
the enrollee would like to continue care with this provider. The Plan denied your request. The Plan says 
enrollees must receive their care from a network provider. 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 hospital outpatient clinic visit, the lab services, 
and the infusion therapy services provided on December 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation, per site 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the requested service is not listed as a 
covered benefit with your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 a 
bone replacement graft for ridge preservation, per site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation. You say that this is needed to meet the enrollee's 
mobility and functional needs. The Plan denied your request. The Plan says a power seat elevation feature is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation feature for a power wheelchair.