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

 
We decided that the Plan does not have to pre-approve the biologic materials to aid in soft and osseous tissue 
regeneration (D3431). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve the 
biologic materials to aid in soft and osseous tissue regeneration (D3431).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that no one 
takes insulin 3 times per day anymore. You also say that you will still have to check your glucose level 3 times 
per day even if you don't take insulin 3 times a day. The Plan denied your request. The Plan says you do not 
require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the new patient office visit provided on 
July 22, 2022. 
 
You asked the Plan to waive the copayment for the new patient office visit. You say that you believe you 
should not be charged 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 $30 
copayment for medical care or surgery services in a specialty physicians office. 
 
You have been asked to pay a $30 copayment for the new patient office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 new patient office visit provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 an office visit provided on April 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
September 23, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. 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 $175 
copayment for each Medicare-covered outpatient diagnostic tests. Covered services include but are not limited 
to diagnostic Imaging (CT scan, MRI/MRA, Myocardial Nuclear Perfusion Imaging and PET scans). The 
provider billed in the amount of $1,139 and the allowed amount is $131.72. This is less than the copayment 
amount. Therefore, results in the total cost sharing amount of $131.72. 
 
 
 
 
 You have been asked to pay a $131.72 copayment, which is less than the copayment for MRI. 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 magnetic resonance imaging (MRI) on September 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for magnetic resonance imaging (MRI) scans 
provided on September 17, 2021, and January 11, 2022. 
 
You asked the Plan to waive the copayments for MRIs. You say that your documents say there are $0 
copayments, why are these large amounts coming now? 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay the 
allowed amount of $200.61 and $234.74, which is less than the $350 copayment for MRIs ($200.61 + $234.74 
= $435.35). 
 
You have been asked to pay a $435.35 combined copayment for MRIs. 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 copayments for magnetic resonance imaging (MRI) scans 
provided on September 17, 2021, and January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9223, D9222) provided 
on September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 deep 
sedation/general anesthesia (D9223, D9222) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #13 (D7953). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site tooth #13 
(D7953). You say that you are asking for a review and to reconsider the coverage for code D7953. The Plan 
denied your request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation - per site tooth #13 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #19 and gingival irrigation 
(D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct 
because the crown and gingival irrigation 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 a 
crown (D2740) for tooth #19 and gingival irrigation (D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve eye services. You say that the Plan does not have enough information to 
rule correctly on this issue. The Plan denied your request. The Plan says there are other providers that are in-
network in the area. 
 
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 
eye services 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 pay for a periodic oral evaluation (D0120) and an adult prophylaxis 
(D1110) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went in for a covered $0 copayment 
examination and cleaning. You also say that the Plan's description does not say that if an enrollee receives the 
$1,500 benefit, then the enrollee loses the examination and cleaning. 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 January 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and an adult 
prophylaxis (D1110) provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and 
specialist office visits provided on June 2, 2022, to June 30, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and specialist office visits. 
You say that you disagree with the cost share. 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 Part B prescription drugs and a $35 copayment per visit for physician/practitioner 
services/specialist services.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $35 copayment 
for specialist office visits. The total allowed amount for the prescription drugs is $21,239.10. You are being asked to pay $4,247.82 ($21,239.10 x 20% = $4,247.82). The total amount for the specialist office visit is $70 
($35 x 2visits =$70). The total amount you are being asked to pay for all services is $4,317.82 ($4,247.82 + 
$70 = $4,317.82). 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 share for Medicare Part B prescription 
drugs and specialist office visits provided on June 2, 2022, to June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant (D4263), and surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve the bone replacement graft  retained natural tooth  first site in quadrant 
(D4263), and surgical placement of implant body: endosteal implant (D6010). You say that these services are 
needed. 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 a 
bone replacement graft  retained natural tooth  first site in quadrant (D4263), and surgical placement of 
implant body: endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee needs a CGM so they can 
achieve better glycemic control. The Plan denied your request. The Plan says the Medicare criteria were 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 and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized with arterial blood gases (ABGs) consistent with acute on 
chronic hypercarbic respiratory failure. The enrollee has severe obesity and a diagnosis of obesity 
hypoventilation syndrome. The enrollee also has obstructive sleep apnea (OSA) and pulmonary hypertension 
with heart failure with preserved ejection fraction (HFpEF). There is no diagnosis of  chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or neuromuscular disease. The enrollee may benefit 
from bilevel positive airway pressure (BiPAP) during sleep as an outpatient. There is no documentation that 
this has been tried and failed as an outpatient according to Medicare criteria. Medicare does not cover a home 
ventilator when used as BiPAP, or for the treatment of obesity hypoventilation syndrome (OHS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from July 8, 2022, to August 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that an NOA was submitted for the first billing 
period. The Plan denied your request. The Plan says that there is no valid NOA claim on file. 
 
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. 
 
We looked at the file and the rules. The case file shows that an NOA was submitted. The appeal indicates that 
the claim for the first billing period was paid. The Plan did not include the NOA provided to show that it was 
invalid. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the home 
health services provided from July 8, 2022, to August 6, 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: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning services (D9120) 
provided on July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 fixed 
partial denture sectioning services (D9120) provided on July 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an EGD. You say that this should be covered. The Plan denied your request. 
The Plan says this provider went out-of-network at the beginning of the year. 
 
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 
an esophagogastroduodenoscopy (EGD) to be provided by an out-of-network (OON) provider.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do 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 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 the enrollee cannot benefit from intensive rehabilitation while she is partial weight 
bearing. Intensive therapy is not indicated.  
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.