Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2. 
 
You asked the Plan to pre-approve FreeStyle Libre 2. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
FreeStyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
FreeStyle Libre 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CGM and supplies have been met. 
Specifically, medical records were requested but not received. Medical necessity cannot be established without 
this documentation. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and ear wax removal provided on November 
03, 2022. 
 
You asked the Plan to pay for the office visit and ear wax removal. You say that the provider should be listed 
as a network provider. 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 office visit and ear 
wax removal provided on November 03, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. You also say that this should be reprocessed and paid. 
The Plan denied your request. The Plan says that the claim processed correctly. 
 
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's rationale is not supported. The file shows that the rules 
cited do not appear to prohibit payment to the program if the prescribing physician is listed on the claim. 
Therefore, we decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) 
provided on October 10, 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: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
September 12, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the facility is certified by the Substance 
Abuse and Mental Health Services Administration (SAMHSA). You also say that this should be paid. The Plan 
denied your request. The Plan says that the claim processed correctly. 
 
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's rationale is not supported. The file shows that the rules 
cited do not appear to prohibit payment to the program if the prescribing physician is listed on the claim. 
Therefore, we decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) 
provided on September 12, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain fused to high noble metal tooth #18 (D2750), 
and core buildup, including any pins when required tooth #18 (D2950). 
 
You asked the Plan to pre-approve the crown - porcelain fused to high noble metal tooth #18 (D2750), and core 
buildup, including any pins when required tooth #18 (D2950). You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 covers the crown - 
porcelain fused to high noble metal tooth #18 (D2750), and core buildup, including any pins when required 
tooth #18 (D2950) when the services are medically necessary and reasonable. 
 
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 crown - porcelain fused to high 
noble metal tooth #18 (D2750), and core buildup, including any pins when required tooth #18 (D2950). Our 
reviewer says that the criteria for coverage for a core buildup (D2950) and crown restoration (D2750) for tooth 
#18 is medically necessary. Our physician reviewer found according to the documentation provided, tooth #18 
had a root canal treatment. Access for a root canal weakens he coronal structure. A core buildup to strengthen 
the coronal structure and provide better retention for a crown restoration is medically reasonable and necessary. 
A crown restoration is medically reasonable and necessary to provide good masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain fused to high noble metal tooth #18 (D2750), and core 
buildup, including any pins when required tooth #18 (D2950) have been met. Therefore, we decided that the 
Plan has to pre-approve a crown - porcelain fused to high noble metal tooth #18 (D2750), and core buildup, 
including any pins when required tooth #18 (D2950).  
 
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 pay for the office visit (99213) provided on September 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient service. You say that the enrollee was seen in an emergency 
situation. You also say that a referral should not be required. 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 (99213) provided on September 8, 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 a mandibular partial denture (D5214) provided on September 
12, 2022. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you believe that this should be 
covered. The Plan denied your request. The Plan says the rendered dental services is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
mandibular partial denture (D5214) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical or vaginal cancer screening; pelvic and clinical 
breast examination (G0101) provided on September 26, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you were experiencing pain and pressure. 
You say that you did not go for a routine yearly exam. You also say that you feel you should not be responsible 
for this bill. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient service have not been met. The record shows that the enrollee received a routine 
exam less than 24 months ago. Additionally, the record does not support that the exam was not routine. 
Therefore, we decided that the Plan does not have to pay for the cervical or vaginal cancer screening; pelvic 
and clinical breast examination (G0101) provided on September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inclisiran injections provided on June 15, 
2022, and September 21, 2022. 
 
You asked the Plan to waive the coinsurance for inclisiran injections. You say that the provider told you these 
injections were covered 100%. You say that you cannot afford to pay the billed amount. 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% in-
network coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.  
 
  You have been asked to pay $1,449.67 for inclisiran injections.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 15, 2022 inclisiran injection $3,900 20% $780 
September 21, 2022 inclisiran injection $3,348.36 20% $699.67 
TOTAL:    $1,449.67 
 
Inclisiran injections fall within the Medicare Part B prescription 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 inclisiran injections provided on June 15, 2022, and September 21, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
20, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom-fitted mandibular sleep apnea appliance (durable 
medical equipment DME) provided on April 18, 2022. 
 
You asked the Plan to pay for a custom-fitted mandibular sleep apnea appliance (durable medical equipment 
DME). You say that this was medically necessary and should be covered. 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 a custom-fitted 
mandibular sleep apnea appliance (durable medical equipment DME) provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses (codes V2781 and V2782) provided on October 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that the vision department is giving you and the treating 
provider the run around. You also say that you are entitled to your discount or reimbursement. The Plan denied 
your request. The Plan says this claim is from a provider who is not in the Plan's network. The Plan also says 
your benefit plan does not cover this OON vision care service/material. 
 
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 these services when you use a Plan-approved network provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received this eyewear from an 
OON provider. Based on this information, we decided that the Plan's rules for coverage of the glasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the glasses (codes V2781 and V2782) 
provided on October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) 
purchased on June 21, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames and progressive lenses. You say that you delivered the reimbursement 
payment, and were never informed of the denial decision. The Plan denied your request. The Plan says you 
received the eyewear from an OON provider. The Plan also says that prior authorization was not obtained. 
 
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 these services when you receive an authorization for Out-of-Network covered 
services. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you did not request prior 
authorization to receive services from an OON provider. Based on this information, we decided that the Plan's 
rules for coverage of the frames and progressive lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames (V2020) and progressive lenses (V2781) purchased on June 21, 2022, from 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on September 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you believe it is imperative that the Plan reimburse 
the provider for all services rendered. The Plan denied your request. The Plan says the service was rendered by 
a non-network provider who does not work with the enrollees health plan, and the enrollee self-directed for 
care. The Plan also says the enrollee's primary care provider did not refer for services, and no medical necessity 
for an OON provider, such as an urgent or emergency situation, has been documented. 
 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 the eye exam (92014) provided on September 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services (97803) provided on 
September 30, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the enrollee's primary care 
physician (PCP) requested the enrollee have a consultation due to their condition. The Plan denied your 
request. The Plan says this service is not covered for this situation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy services (97803) provided on September 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on 
November 18, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you were not satisfied with 
your care, so you are not paying the copayment for this visit. 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 emergency care. 
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service falls within the 
emergency care 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 emergency room visit 
provided on November 18, 2022.