Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  

You asked the Plan to pre-approve 7 home health physical therapy visits. 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 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 clinical 
documentation shows that all appropriate home health PT goals have been met (patient refuses to use 
AD/modifications) thus the records do not show that the requested home health PT sessions are required to 
effectively provide treatment. 
 
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 services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. 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 a complete 
denture - maxillary (D5110), and mandibular (D5120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on June 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting the claim be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. 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 a nursing facility care visit provided on June 22, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that the requested test strips are 
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 test strips. Therefore, we decided that the Plan does not have to pre-approve the Freestyle 
Lite test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249 x 2) provided on June 
19, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider advised you this was a covered 
procedure. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
clinical crown lengthening (D4249 x 2) provided on June 19, 2023.
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 a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have 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. 
Based on this information, we decided that Medicare rules for coverage of a 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-covered items or services including a specific type 
of underwear (A9270). 
 
You asked the Plan to pre-approve non-covered items or services including a specific type of underwear 
(A9270). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
the adult underwear and size you requested are not an item listed in the OTC catalog. The Plan also says that 
therefore, the request to use your OTC benefit for your requested brand of adult underwear is not a 
covered benefit and is denied. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and non-
covered items or services (A9270) is an OTC item. Therefore, we decided that the Plan does not have to pre-
approve non-covered items or services including a specific type of underwear (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft in conjunction with periradicular surgery 
(D3428). 
 
You asked the Plan to pre-approve D3428. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 graft in conjunction with periradicular surgery (D3428).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary. The 
Plan denied your request. The Plan says the requested Rituxan is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituxan. Our reviewer says that the 
requested Rituxan is not medically necessary. Our physician reviewer found Rituxan is not Food and Drug 
Administration-approved for the enrollee's diagnosis. The use of Rituxan for treatment of vasculitic neuropathy 
and polyneuropathy in diseases classified elsewhere is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 provided from February 21, 2023, to 
February 27, 2023. 
 
You asked the Plan to pay for procedure code A4223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4223 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4223 is excluded from Medicare coverage. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4223 provided from February 21, 2023, to February 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 800 units of Botox every 12 weeks for one year.  
 
You asked the Plan to pre-approve 800 units of Botox every 12 weeks for one year. You say that the requested 
dosage increase of Botox to 800 units every 12 weeks for one year is medically necessary.  The Plan denied 
your request. The Plan says the requested dosage increase of Botox to 800 units every 12 weeks for one year is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 800 units of Botox every 12 weeks for 
one year. Our reviewer says that the requested dosage increase of Botox to 800 units every 12 weeks for one 
year is not medically necessary.  Our physician reviewer found based on the medical records provided and the 
Medicare-approved major drug compendia there is no documentation that the Botox at a dose of 800 units 
every 12 weeks for one year in this case meets all Medicare criteria to be medically reasonable and necessary 
and safe and effective for the enrollee. The compendia all consistently state that the maximum safe dose of 
Botox for spasticity is 400 units every 12 weeks. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 800 units of Botox every 12 weeks for one year have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 800 units of Botox every 12 weeks for one year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5225) provided on June 30, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the treatment to be approved as 
you have been going to the same dentist for other treatments. 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 the maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) 
(D5225) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on June 5, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. The Plan denied your request. The Plan says your 
benefit for the limited oral evaluation 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 dates of service May 2, 2023 and May 10, 2023. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the teeth box you have does not fit 
anymore in your mouth and you cannot eat normally. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 for a complete upper denture (D5110) and a complete lower denture (D5120) on October 
21, 2019; therefore, your benefit for the requested items or services was exhausted on the date of service of 
October 21, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
(96365, 96366, 96521) provided on February 14, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services (96365, 96366, 96521) provided on 
February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99214-25 billed for date of service May 15, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code is 
included in the global period for code 20610. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99214-25 is not supported in the medical record. Specifically, the records do now show 
that the evaluation and management service was a significantly separate identifiable service. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for 99214-25 billed for date of service May 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
18, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reprocessed for 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revenue code 0291 billed for dates of service April 1, 2023, 
to April 18, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an appropriate 
code was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that revenue code 0291 was not billed with an appropriate procedure code as required. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for revenue code 0291 billed for dates of service April 1, 2023, 
to April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the general anesthesia (D9222 and D9223) and the 
therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the denied dental services 
covered because you were advised by your surgeon that they were necessary. The Plan denied your request. 
The Plan says the denial of authorization for these services is correct, because the general anesthesia and the 
therapeutic parenteral drug are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
general anesthesia (D9222 and D9223) and the therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower 
denture (D5140), and an extraction (D7140) provided on January 26, 2023, and February 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are getting billed by a participating provider 
and you should not have to pay more because they never advised you of the maximum benefits. 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 $1,000 for dental services on January 26, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 26, 2023. Therefore, we decided 
that the Plan does not have to pay for an immediate upper denture (D5130), an immediate lower denture 
(D5140), and an extraction (D7140) provided on January 26, 2023, and February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 dental extractions (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you need these extractions. 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 with the approval of one D7210. Therefore, 
we decided that the Plan does not have to pre-approve 17 dental extractions (D7210).