Persius/hicric huggingface dataset:
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 are requesting an expedited 
reconsideration stating the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 is improving but still requires acute care services, and these have not 
been denied by the Plan. The medical record does not indicate that the enrollee requires services that they are 
not currently receiving but that would be available at the LTACH facility. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750), and pontics (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that you would like this dental work approved. 
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 Plan has 
approved four D6750/D6240 already, therefore; we decided that the Plan does not have to pre-approve retainer 
crowns (D6750), and pontics (D6240).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 11, 2022, to 
October 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there is an NOA on file. 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 looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue is 
not 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 October 11, 2022, to October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the items. You say that the provider accepts the Medicare in-network 
allowance amount as full payment and do not generate a charge to the enrollee. The Plan denied your request. 
The Plan says the items can be provided in-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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor and segmental pneumatic appliance to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection and drug administration 
provided on December 13, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injection and drug administration. You say that you 
are on a fixed income and cannot afford this payment. 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 35% 
coinsurance for out-of-network Medicare Part B drugs. 
 
You have been asked to pay 35% coinsurance for the drug injection and drug administration. This item/service 
falls within the out-of-network Medicare Part B drugs 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 
coinsurance for the drug injection and drug administration provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on August 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you want to upgrade your CGM from a 
Dexcom G6 to a Dexcom G7 because you are having issues with your G6. The Plan denied your request. The 
Plan says replacement due to daily wear is not covered during the first three years, however repair costs can be 
covered during this time. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, carriers 
may determine the RUL, but in no case can it be less than five years. 
  We looked at the file and Medicare rules. The documentation indicates that you were approved for a 
therapeutic CGM on July 20, 2022, therefore, your benefit has been exhausted. A therapeutic CGM, in no case, 
can be replaced less than five years. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 21, 2022, to April 
28, 2022. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says a NOA was never received. As such, this final claim was correctly 
denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 21, 2022. The NOA was not received by the Plan. As more than 30 
days passed, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay 
for home health services provided on April 21, 2022, to April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble Metal for tooth #8 
(D6240) and pontic - porcelain/ceramic for teeth #6, #7, #9 and #12 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve pontic - porcelain fused to high noble Metal for tooth #8 (D6240) and pontic - 
porcelain/ceramic for teeth #6, #7, #9 and #12 (D6245).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on July 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told everything would be covered. The 
Plan denied your request. The Plan says that your benefit for the service or item has been exhausted. 
 
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 forward the Evidence of Coverage for the year of 
2022. Without this necessary documentation we are unable to make a determination as to whether the benefit 
limit for the comprehensive oral evaluation was exhausted. Therefore, we decided that the Plan has to pay for a 
comprehensive oral evaluation (D0150) provided on July 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the phlebotomy services provided on 
January 25, 2023. 
 
You asked the Plan to reduce the copayment for the phlebotomy services. You say that your plan should pay a 
larger share for this service. 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 $90 
copayment for in-network outpatient diagnostic procedures and tests. 
 
You have been asked to pay a $90 copayment for the phlebotomy services. This item/service falls within the in-
network outpatient diagnostic procedures and 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 reduce the 
copayment for the phlebotomy services provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstuction (D3331) and 
intraorifice barrier (D3911). 
 
You asked the Plan to pre-approve treatment of root canal obstuction and intraorifice barrier. 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 pre-approve 
treatment of root canal obstuction (D3331) and intraorifice barrier (D3911).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on August 31, 2022. 
 
You asked the Plan to pay for injections. You say that the services were medically necessary. 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 injections provided on 
August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on . 
 
You asked the Plan to pay for IRF care. You say that it is medically necessary. The Plan denied your request. 
The Plan says the enrollee does 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 pay for 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 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. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. There is not a reasonable expectation that this 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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided on .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction (D7210 x2), deep sedation/general 
anesthesia first 15 minutes (D9222 x2), deep sedation/general anesthesia  each subsequent 15-minute 
increment (D9223 x2), and therapeutic parenteral drugs (D9612x2), alveoplasties (D7310) and removal of torus 
mandibularis  
(D7473 x2). 
 
You asked the Plan to pre-approve surgical extractions, anesthesia, parenteral drugs, alveoplasties and removal 
of torus mandibularis. You say that this should be covered. The Plan denied your request. The Plan says these 
are not covered services. 
 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 
surgical extraction (D7210 x2), deep sedation/general anesthesia first 15 minutes (D9222 x2), deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223 x2), and therapeutic parenteral 
drugs (D9612x2), alveoplasties (D7310) and removal of torus mandibularis  
(D7473 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crestor tablet 10mg. 
 
You asked the Plan to pre-approve Crestor tablet 10mg. You say that the enrollee is unable to tolerate the 
generic form. The Plan denied your request.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor tablet 10mg.  Benefits for Crestor 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee was in a nursing home and couldnt 
choose a lab. 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 laboratory services 
provided on September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99203) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the service should be covered. The Plan denied 
your request. The Plan says there are in-network providers that can perform this service. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
Tooth #5 and crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the services approved. 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 core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) but 
is limited to one per tooth every five years with appropriate justification. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered core buildup, including any pins when required (D2950) on November 18, 2021, 
and crown - porcelain/ceramic (D2740) on December 14, 2021. Therefore, these benefits were exhausted as of 
December 14, 2021. Therefore, we decided that the Plan does not have to pre-approve core buildup, including 
any pins when required (D2950) Tooth #5 and crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065), 
and prefabricated abutment  includes modification and placement (D6056). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crown, and prefabricated abutment 
 includes modification and placement. You say that you do not agree with the denial as this is medically 
necessary to you. The Plan denied your request. The Plan says these services are 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 pre-approve an 
implant supported porcelain/ceramic crown (D6065), and prefabricated abutment  includes modification and 
placement (D6056).