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

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on October 14, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the visit was due to diabetes. You 
say the copayment should be waived because it is covered by Medicare. 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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 You have been asked to pay a $45 copayment for the eye exam. This service falls within the vision care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
The medical record shows you were seen for a diabetic eye exam which is medical in nature. 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 October 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need long-term care. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and your needs can be 
met in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care setting.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder (ILR) is used when 
syncope is thought to be cardiac-related, but is too infrequent to be detected by either a HolterTM monitor or a 
traditional pre-symptom MLR. 
 
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 an ILR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine examination and the progressive lenses provided 
on September 20, 2022. 
 
You asked the Plan to pay for the routine examination and the progressive lenses. You say that you have 
received the full allowance of $200 in the past. The Plan denied your request. The Plan says the benefit limits 
have been exhausted. 
 
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 routine eye examinations once a year and up to $200 towards the progressive lenses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a routine examination on March 9, 
2022, which exhausted the benefit. Also, the Plan paid $144 towards the progressive lenses, and you have no 
financial responsibility for the lenses. Based on this information, we decided that the Plan's rules for coverage 
of the routine examination and the progressive lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the routine examination and the progressive lenses provided on September 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services (97026) provided from May 6, 
2022, to September 21, 2022. 
 
You asked the Plan to pay for the infrared therapy services. You say that there should be no denial for these 
modalities. The Plan denied your request. The Plan says these services do not meet the Medicare criteria. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy services (97026) provided from May 6, 2022, to September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supply 
allowance. 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that the sensors are medically 
necessary to control your diabetes. The Plan denied your request. The Plan says you do not require insulin three 
or more times daily. 
 
 
 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supply allowance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye examination provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for the medical eye examination. You say that you went for a 
routine eye exam and was under the impression that the exam was totally covered. 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 $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye.  
 
 You have been asked to pay a $35 copayment for the medical eye examination. This service falls within the 
vision care benefit category. The medical record shows diagnoses of hypermetropia, macular degeneration, and 
cataracts which makes the eye exam medical in nature. 
 
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 medical eye examination provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM because the 
previous CGM was lost, stolen, or damaged. The Plan denied your request. The Plan says that additional 
coverage for the CGM is not authorized. 
 
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 collect medical records from their participating 
provider who ordered the requested CGM. Participating providers are considered agents of the Plan. Without 
this necessary documentation we are unable to make a determination as to whether the enrollee has met the 
criteria for coverage of a CGM. Also, the provider sent documentation annotating the previous CGM was 
damaged, lost, or stolen. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor 
(CGM).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary, and 
it would be unfortunate to deny the opportunity to be weaned from the ventilator, as skilled nursing facilities do 
not have that capability. The enrollee also has acute kidney injury requiring hemodialysis and treatment that 
could not be given in a lower level of care. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230) provided on 
November 16, 2022. 
 
You asked the Plan to pay for inhalation of nitrous oxide/analgesia. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for inhalation 
of nitrous oxide/analgesia (D9230) provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on September 19, 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 compression stockings identified with code (A6549). 
 
You asked the Plan to pre-approve the compression stockings. You say that your doctor recommended these 
stockings for your on-going medical  condition. The Plan denied your request. The Plan says you do not have a 
qualifying wound for coverage of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code (A6549) are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code (A6549).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip replacement (27130). 
 
You asked the Plan to pre-approve a total hip replacement. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a Total Hip Arthroplasty (THA) is considered 
reasonable and necessary for individuals with one or more of the conditions listed 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 a total hip replacement. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the recent imaging demonstrated 
some narrowing of the superior joint space with thinning of the articular cartilage. This does not corroborate 
advanced joint disease. This MRI also failed to corroborate any malignancy, avascular necrosis (osteonecrosis 
of the femoral head), fracture of the femoral neck, acetabular fracture, non-union or failure of previous hip 
fracture surgery, or malunion of acetabular or proximal femur fracture. Therefore, the enrollee does not have 
one or more of the noted conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip replacement (27130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the walker provided on December 05, 
2022. 
 
You asked the Plan to waive the coinsurance for the walker. You say that you were told by physical therapy 
that there would be no cost for this walker. 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 20% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the walker. This item/service falls within the in-network 
durable medical equipment and related supplies 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. The total you owe is $13.94 ($69.71 allowed amount x 20% 
coinsurance = $13.94). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
walker provided on December 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over the bed table (E1399). 
 
You asked the Plan to pre-approve an over the bed table. You say that you need this item. The Plan denied your 
request. The Plan says this item is not medical in nature and is regularly and primarily used by persons who do 
not have a specific medical need for them. 
 
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 an over the bed table (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician (D9310) provided on December 30, 2021. 
 
You asked the Plan to pay for the consultation - diagnostic service. You say that you were unable to locate an 
in-network provider. You also say the provider would not accept you as a patient due to a charges dispute and 
the Plan would apply for an out-of-network exception. 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 a 
consultation - diagnostic service provided by dentist or physician (D9310) provided on December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. 
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for limited oral evaluation - problem focused (D0140), 
intraoral - periapical - first film(D0220) and extraction, erupted tooth, or exposed root (D7140) provided on 
January 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans payment. 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 pay more for limited oral evaluation - problem focused 
(D0140), intraoral - periapical - first film(D0220) and extraction, erupted tooth, or exposed root (D7140) 
provided on January 2, 2023.