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

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) scans (70551, 72141, 
72146) provided on August 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRi scans. 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 the provider is not in 
network with the plan. 
 
  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 magnetic resonance imaging (MRI) scans (70551, 
72141, 72146) provided on August 26, 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 a medical eye examination (92012) provided on August 08, 
2022. 
 
You asked the Plan to pay for a medical eye examination (92012). You say that you have submitted medical 
records to show services rendered were medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92012) provided on August 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 CGM. 
 
You asked the Plan to pre-approve the Dexcom G6 CGM. 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  not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Dexcom 
G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065), 
prefabricated abutment  includes modification and placement (D6056), and surgical placement of implant 
body: endosteal implant (D6010) all for tooth #'s 13 and 14. 
 
You asked the Plan to pre-approve codes D6065, D6056 and D6010 all for tooth #'s 13 and 14. The Plan denied 
your request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported porcelain/ceramic crown (D6065), prefabricated abutment  includes modification and 
placement (D6056), and surgical placement of implant body: endosteal implant (D6010) all for tooth #'s 13 and 
14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a complete 
maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are currently unable to eat properly. 
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 7, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a complete 
maxillary denture (D5110).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ultrasound of the abdomen 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for an in-network ultrasound of the abdomen. You say that the 
Plan didn't pay anything towards this test, and you do not know why. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. The allowed amount charged was less than your copayment for 
this service. 
 
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 $100 
copayment for other outpatient diagnostic tests, radiological diagnostic services not including x-rays.  
 
You have been asked to pay the allowed amount of $95.77 which is less than the $100 copayment for an in-
network ultrasound of the abdomen. This item/service falls within the other outpatient diagnostic tests, 
radiological diagnostic services not including x-rays 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 an in-network ultrasound of the abdomen 
provided on October 18, 2022.
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 requested IRF services are medically necessary. 
The Plan denied your request. The Plan says the IRF services requested 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 16, 2021 and 
June 17, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says there is no 
medical evidence of an emergency, no life at risk, no PCP referral and no preauthorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care provided on June 16, 2021 and 
June 17, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on September 27, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you have never had to pay this much out 
of pocket before. 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 $15 
copayment for each Medicare-covered in-network standard x-ray and ultrasound.  
 
You have been asked to pay a $15 copayment for an x-ray. This item/service falls within the Medicare-covered 
in-network standard x-ray and ultrasound 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 an x-ray provided on September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 28, 2022. 
 
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 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 an office visit provided 
on November 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on May 23, 2022. 
 
You asked the Plan to pay for imaging 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 imaging services provided on May 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) and magnetic resonance 
angiography (MRA) received on March 22, 2022. 
 
You asked the Plan to pay for the MRI and MRA. The Plan denied your request. The Plan says services should 
be billed to Original Medicare. 
  
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 March 8, 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 magnetic resonance 
imaging (MRI) and magnetic resonance angiography (MRA) received on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 2) and bone grafts at the time of implant placement (D6104 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of an implant body: endosteal implants (D6010 x 2) and bone grafts at the time of implant placement 
(D6104 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of an implant body: endosteal implants (D6010 x 4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis injections with imaging guidance provided on 
October 27, 2022. 
 
You asked the Plan to pay for arthrocentesis injections with imaging guidance. You say that you are appealing 
the claim payment denial. 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 arthrocentesis injections 
with imaging guidance provided on October 27, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on August 31, 
2022. 
 
You asked the Plan to pay for chronic care management services. You say that you are requesting 
reconsideration. 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 chronic care 
management services provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre Kit 2 sensor. 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 a 
FreeStyle Libre Kit 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre Kit 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on June 27, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration. 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 ophthalmological 
services provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from May 26, 2022, 
through May 29, 2022. 
 You asked the Plan to pay for inpatient hospital services. You say that the enrollee was not enrolled in hospice 
during their inpatient stay. 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. 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 May 23, 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 inpatient hospital services 
provided from May 26, 2022, through May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services provided from October 12, 
2021, through October 20, 2021. 
 
You asked the Plan to pay for subsequent hospital care services. You say that the enrollee's hospice services 
were revoked on October 10, 2021, and the claim needs to be reprocessed. The Plan denied your request. The 
Plan says that 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 October 10, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care services provided from October 12, 2021, through October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided on May 14, 2022, to 
June 3, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you feel the copayment should be 
fully covered by the Plan. 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 $295 
copayment per day for days 1-7 and $0 copayment per day for days 8-90 for covered inpatient hospital stays.  
 
You have been asked to pay a total copayment of $2,065 for an IRF stay ($295 per day x 7 days = $2,065). 
This item/service falls within the covered inpatient hospital stays 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 an IRF stay provided on May 14, 2022, to June 3, 2022.