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

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the billed service should be paid for by 
your insurance because you have had few dental claims. 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 limited oral evaluation - problem focused (D0140) but is limited to one procedure per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You 
previously received covered  limited oral evaluation - problem focused (D0140) on date of service June 11, 
2022. Therefore, this benefit was exhausted on June 11, 2022. Therefore, we decided that the Plan does not 
have to pay for limited oral evaluation - problem focused (D0140) provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided on December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you weren't aware of the coverage rules, or you 
wouldn't have done the imaging. 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 on date of service June 28, 2021. Therefore, 
we decided that the Plan does not have to pay for panoramic x-rays (D0330) provided on December 6, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested drug 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 Leqvio. Our reviewer says that the 
documentation does support that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee has a diagnosis of atherosclerotic cardiovascular disease with a history of coronary 
artery bypass surgery in 2014 and a percutaneous coronary intervention in 2022 with an low-density lipoprotein 
(LDL) cholesterol of 74 mg/dL and a reported intolerance to statins and PCSK9 inhibitors (severe leg 
cramping). Leqvio (inclisiran) is Food and Drug Administration-approved as an adjunct to diet and maximally 
tolerated statin therapy to treat adults with clinical atherosclerotic cardiovascular disease (ASCVD) who 
require additional lowering of LDL-cholesterol. Based on the medical records provided and the Medicare-
approved major drug compendia there is documentation that the Leqvio at issue in this case meets all Medicare 
criteria for safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have been met. Therefore, we decided that the Plan has to pre-approve 
Leqvio.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81503). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the OVA1 test is indicated for women who meet the 
following criteria: over age 18, ovary with a mass present for which surgery is planned, and not yet referred to 
an oncologist. 
 
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 genetic testing. Our reviewer says 
that this service is not medically necessary. Our physician reviewer found the record provided does not 
establish that a mass is identified and that surgery is planned. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81503).
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 services are necessary for you to receive medical 
assistance with your health and recovery from your surgery. The Plan denied your request. The Plan says you 
could receive your care in another setting. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 13, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs assistance with everyday life 
functioning. The Plan denied your request. The Plan says the records do not show that the enrollee is are able to 
tolerate 3 hours of therapy a day at least 5 days a week or 15 hours per week. 
 
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 enrollee's 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 right foot pain and infection and had a below the knee amputation. Medical problems 
are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 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 pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program services provided on October 24, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that an 
individual provider cannot bill for the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the billing provider is an eligible opioid treatment program provider. Based on this information, 
we decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that 
the Plan has to pay for the opioid treatment program services provided on October 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Lite glucose meter with related supplies. 
 
You asked the Plan to pre-approve the FreeStyle Lite glucose meter with related supplies. You say that you are 
appealing the denied service. 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 FreeStyle Lite glucose meter with related supplies. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Lite glucose meter with related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve amphetamine/dextroamphetamine Tab 20mg. 
 
You asked the Plan to pre-approve a prescription medication. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested medication is a self-administered drug. The medication 
does not fall under Part B coverage. 
 
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 
amphetamine/dextroamphetamine Tab 20mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that it is medically necessary that 
the enrollee receive the CGM because they cannot check their glucose when they are alone. The Plan denied 
your request. The Plan says records do not show the enrollee has a history of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and related supplies. Our 
reviewer says that the CGM is not medically necessary. Our physician reviewer found that the enrollee does 
not have low blood glucose (BGS) and is not taking insulin or medication that causes low BGS. The criteria 
state that an enrollee needs to be on insulin or have a hypoglycemia of low BGS; this enrollee does not satisfy 
the criteria. We are not told why this enrollee must check BGS with at goal A1c and not on a medication that 
can cause low BGS. 
 
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 CGM and related supplies. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient 
(D0150) provided on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider did an x-ray over your objection, so 
you should not have to pay for the billed service. 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  new or established patient (D0150) but is limited to one procedure 
every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you previously received covered D0150 on date of service March 10, 2022, therefore, this benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation  
new or established patient (D0150) provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on August 01, 
2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that this service was 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 magnetic resonance 
imaging (MRI) provided on August 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010) and bone graft at time of implant placement (D6104) provided on October 6, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have any out-of-pocket expense for 
the services because you see a participating provider. The Plan denied your request. The Plan says this service 
is not covered under your 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. Surgical placement of implant 
body: endosteal implant (D6010) and bone graft at time of implant placement (D6104) are not covered under 
the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010 and D6104 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement 
(D6104) provided on October 6, 2022.
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 enrollee needs to be transferred to an 
acute care facility for continued acute care monitoring to avoid sepsis. The Plan denied your request. The Plan 
says the enrollee can safely receive this care in another 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on December 13, 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 was medically 
necessary. 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 (99215) provided on December 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on 
October 27, 2022. 
 
You asked the Plan to pay for 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 on date of service July 11, 2022. Therefore, 
we decided that the Plan does not have to pay for limited exam to evaluate a problem (D0140) provided on 
October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92004) provided on September 19, 2022. 
 You asked the Plan to pay for the eye exam. You say that the second eye exam was medically necessary. The 
Plan denied your request. The Plan says the benefit for eye exams has 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 one routine eye exam per year. 
 
We looked at the file and the Plan's rules. A routine eye exam was already covered by the plan. Only one eye 
exam is covered per year. Based on this information, we decided that the Plan's rules for coverage of the eye 
exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92004) 
provided on September 19, 2022.