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

 
We decided that the Plan does not have to waive the cost sharing for the radiation therapy services provided on 
November 16, 2022. 
 
You asked the Plan to waive the cost sharing for the radiation therapy services. You say that you do not think 
you should be responsible for paying for these services. 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 20% 
coinsurance for Medicare-covered therapeutic radiology services. 
 
You have been asked to pay a $91.68 coinsurance for the radiation therapy services ($458.42 allowed amount x 
.20 = $91.68). These items/services fall within the outpatient diagnostic tests and therapeutic services and 
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. Therefore, we decided that the Plan does not have to waive the cost sharing for the radiation therapy 
services provided on November 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound performed on 
August 3, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not understand the 
copayment applied to 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 $150 
copayment for Medicare-covered radiological diagnostic services, which includes ultrasounds, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
 
 
 You have been asked to pay a $92.84 copayment for the ultrasound because the allowed amount for this service 
is less than the $150 copayment. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
abdominal ultrasound performed on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the denosumab injection provided by an 
in-network provider on December 29, 2022. 
 
You asked the Plan to waive the cost sharing for the injection. You say that you were not aware of the cost 
sharing 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 20% 
coinsurance for each in-network Medicare-covered Part B drug. 
 
You have been asked to pay a $270.12 coinsurance for the injection ($1350.60 allowed amount x .20 = 
$270.12). This item/service falls 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 cost sharing for the denosumab injection provided by an in-network provider on 
December 29, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from July 15, 2022, to July 21, 
2022. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on July 9, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from July 15, 2022, to July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) Tooth #20 and 
retainer crown - porcelain/ceramic (D6740) Tooth #19 and 21. 
 
You asked the Plan to pre-approve dental services. You say that you would like your insurance to reconsider 
approving the requested services that you need. 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. Pontic - porcelain/ceramic and 
retainer crown - porcelain/ceramic are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6245 and D6740 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain/ceramic (D6245) Tooth #20 and retainer crown - porcelain/ceramic (D6740) Tooth #19 and 
21.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management. As such, the request for this 
service is considered experimental/investigational for the evaluation and management of your medical 
condition. 
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography (CT), of the heart, without contrast material, with 
quantitative evaluation of coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift/glide provided on April 7, 2022, to April 8, 2022. 
 
You asked the Plan to pay for a stair lift. You say that you would like reconsideration because the requested 
stair lift is medically necessary. The Plan denied your request. The Plan says the requested stair lift is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift/glide provided on April 7, 2022, to 
April 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on August 13, 2022. 
 
You asked the Plan to pay for hospital services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on August 13, 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 an LTACH level of care is the only 
option for a safe discharge. The Plan denied your request. The Plan says the member's care can be provided in 
the current hospital. 
 
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 appears to be improving but requires additional short-term acute care 
services that can safely be provided at the current facility until more stable and appropriate for a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current facility. 
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is recommended. 
 
 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: 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 you need rehabilitation services. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition. The enrollee is receiving appropriate 
care at the present acute care hospital. 
 
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: 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 member meets IRF criteria and is reasonably 
expected to participate in the required rehabilitation. The Plan denied your request. The Plan says the member 
does not meet the requirements for an IRF admission. 
 
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 clinical documentation shows that the enrollee has active medical comorbidities 
(uncontrolled HTN); However, documentation does not specify any complex functional impairments thus the 
complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria is 
not met. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that you say that due to your disability you 
have a hard time checking your blood sugar. You are not on insulin yet, but if you can get the CGM approved, 
it may prevent that from happening. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic CGM.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on January 16, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that the doctor is seeking reimbursement for the 
medically necessary services provided to the enrollee. The Plan denied your request. The Plan says this 
provider is not a network provider. 
 
 
 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 physical therapy (PT) services provided on 
January 16, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray exam provided on September 2, 2022. 
 
You asked the Plan to pay for an X-ray exam. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an X-ray exam provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2022. 
 
You asked the Plan to pay for an office visit. You say that the enrollee was not in hospice. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray exam provided on May 17, 2022. 
 
You asked the Plan to pay for an X-ray exam.. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an X-ray exam provided on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy provided on December 13, 
2022. 
 
You asked the Plan to pay for esophagogastroduodenoscopy. You say that the enrollee was not in hospice at the 
time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for esophagogastroduodenoscopy provided on December 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 sensor. 
 
You asked the Plan to pre-approve Dexcom G6 sensor. You say that the enrollee is frequently adjusting insulin 
dosages for the next six months. You also say that the enrollee is having very high glucose readings at home. 
The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 does not indicate that the enrollee usse insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 
sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement grafts (D4264) for tooth #24 and 
#26. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary 
so the enrollee can have comfort with their dentures. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the bone replacement grafts are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement grafts (D4264) for tooth #24 and #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing the SSBCI program 
denial. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of the SSBCI benefits have been met. Therefore, we decided that the Plan does 
not have to pre-approve the SSBCI benefits.