Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transport. 
 
You asked the Plan to pre-approve the non-emergency ambulance transport. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the records provided do not show that 
ground ambulance is needed for your transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transport. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on 
the limited documentation provided there is no indication of what this requested transportation is for. There is 
no evidence that the enrollee is bedbound. As such, it is not shown that the use of an ambulance for any 
transportation is medically necessary or reasonable. 
 
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 non-emergency ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transport.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 11, 2022, to 
April 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. 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 March 11, 2022, to April 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an invalid dental code (D0000) and an implant (D6010) 
for tooth #15. 
 
You asked the Plan to pre-approve the dental service. You say that the implant was previously approved and 
would like the Plan to approve it again. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because dental implants and all associated services 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 an 
invalid dental code (D0000) and an implant (D6010) for tooth #15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on September 08, 
2022. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the copaymet. 
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 $10 
copayment for outpatient diagnostic tests/Medicare-covered laboratory tests. 
 
You have been asked to pay a $10 copayment for laboratory tests. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered laboratory tests benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for laboratory tests provided on September 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - four or more surfaces, posterior 
(D2394) provided on August 9, 2022. 
 
You asked the Plan to pay for the resin-based composite - four or more surfaces, posterior (D2394) provided on 
August 9, 2022. You say that you went to your regular dentist to get fillings and received a denial due to the 
type of material used. You also say that you think something should be paid on this claim. The Plan denied 
your request. The Plan says you do not show that you have the optional benefit that covers comprehensive 
dental services, therefore the claim is not payable. 
 
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 a resin-
based composite - four or more surfaces, posterior (D2394) provided on August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance. for out-of-network outpatient laboratory 
services provided on April 7, 2021. 
 
You asked the Plan to waive the coinsurance. for out-of-network outpatient laboratory services. You say that 
you disagree with the coinsurance. 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 50% 
coinsurance for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a 50% coinsurance for out-of-network outpatient laboratory services. The total 
allowed amount for the lab services $55.87 ($55.87 x 50% = $27.94). 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 
coinsurance. for out-of-network outpatient laboratory services provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on August 16, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you belive the services should be 
cvered under cancer screening. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient surgery. 
 
You have been asked to pay a $150 copayment for colonoscopy. This item/service falls within the outpatient 
surgery 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 colonoscopy provided on 
August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on September 01, 2022. 
 
You asked the Plan to pay for the injections. You say that staff was not informed that authorization was 
required. 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 injections provided 
on September 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival irrigation (D4921) for the upper left, lower left, 
upper right, and lower right quadrants, a two dimensional oral/facial photographic image (D0350), oral hygiene 
instructions (D1330), and an intraoral - periapical each additional radiographic image (D0230) provided on 
August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental provider charged you for deep dental 
cleaning, not regular dental cleaning. The Plan denied your request. The Plan says your benefit for an intraoral 
- periapical each additional radiographic image (D0230) was exhausted with this claim. The Plan also says that 
there is no coverage for a gingival irrigation (D4921) for the upper left, lower left, upper right, and lower right 
quadrants, a two dimensional oral/facial photographic image (D0350), and oral hygiene instructions (D1330). 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 Plan rules say that you are 
limited to one procedure code per calendar year for an intraoral - periapical each additional radiographic image 
(D0230). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for an intraoral - periapical each additional radiographic image (D0230) was exhausted with 
this appeal claim. The record also shows that there is no coverage for a gingival irrigation (D4921) for the 
upper left, lower left, upper right, and lower right quadrants, a two dimensional oral/facial photographic image 
(D0350), and oral hygiene instructions (D1330). Therefore, we decided that the Plan does not have to pay for a 
gingival irrigation (D4921) for the upper left, lower left, upper right, and lower right quadrants, a two 
dimensional oral/facial photographic image (D0350), oral hygiene instructions (D1330), and an intraoral - 
periapical each additional radiographic image (D0230) provided on August 3, 2022.  
 
Your complaint about the potentially dishonest service provided by the dental group is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the patient was referred to an ophthalmologist five times but states she will not see any 
of these ophthalmologists. The Plan denied your request. The Plan says a non-contract provider may be needed 
if the Plan does not have a provider that cannot provided the services. The services are available within the 
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says the services provided by an out of network provider were not 
authorized. Services can be obtained by an in-network provide. 
 
 
 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 an office visit provided on August 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (GCM). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you have been on this for years. 
The Plan denied your request. The Plan says the medical criteria for a GMA have not been met. 
 
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 a continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (GCM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more help to return to baseline. 
The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Buprenorphine patch. 
 
You asked the Plan to pre-approve Buprenorphine. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Buprenorphine patch.  
 Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the lower abdomen provided on  
May 12, 2021. 
 
You asked the Plan to pay for anesthesia for procedures on the lower abdomen. The Plan denied your request. 
The Plan says that the services are not covered. 
 
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 has not provided a rule to substantiate their denial. 
Therefore, we decided that the Plan has to pay for anesthesia for procedures on the lower abdomen provided on 
May 12, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have osteoarthritis of the left knee. 
You have not tried and failed the Plan's required drug, Euflexxa. The records do not support that the required 
drug would have adverse affects or be less effective; therefore, Synvisc-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation and prophylaxis-adult 
(cleaning) provided on September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay for these services 
because you changed providers, and it was just a few days shy of 6 months. 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. This benefit includes the 
requested comprehensive oral evaluation and prophylaxis-adult (cleaning) but each is limited to one every 6 
months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested periodic oral evaluation and prophylaxis-adult (cleaning) was exhausted 
on date of service March 11, 2022. Therefore, we decided that the Plan does not have to pay for comprehensive 
oral evaluation and prophylaxis-adult (cleaning) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on September 06, 
2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $50 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist visit provided on September 06, 2022.