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

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953) and therapeutic drugs 
(D9612) for tooth #22 and #28. 
 
You asked the Plan to pre-approve the dental services. You say that the denied dental procedures are medically 
necessary and you need it done immediately. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because bone replacement grafts and therapeutic drugs 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 bone 
replacement grafts (D7953) and therapeutic drugs (D9612) for tooth #22 and #28.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), provided on September 7, 2022. 
 
You asked the Plan to pay for the back brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says there is no mention of the braces billed in the referring physician medical records 
provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records submitted do not indicate a back brace was discussed or ordered. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the back brace (L0650), provided on September 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on October 
22, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you disagree with the 
copayment. 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 October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided on 
March 22, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they do not 
fall under the members benefit plan nor do they meet the clinical requirements to be approved for one. 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) 
provided on March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 
11, 2022, to August 17, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $325 
copayment per day for days 1-5 and a $0 for additional hospital days for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-5 and a $0 for additional hospital days for 
inpatient hospital care. The total amount you are being asked to pay $1,625 ($325 x 5days = $1,625). This 
item/service falls within the inpatient hospital 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 inpatient hospital care provided on August 11, 2022, to August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diabetic shoe fitting and shoe inserts provided on August 
29, 2022, by an OON provider. 
 
You asked the Plan to pay for a diabetic shoe fitting and shoe inserts. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee must receive care from 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 a diabetic shoe fitting and shoe inserts provided on 
August 29, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that the LTACH 
services were 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care setting. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network specialist office visits 
provided on October 20, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayment for out-of-network specialist office visits. You say that you 
disagree with the copayments. 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 $85 
copayment for out-of-network physician/practitioner services/specialist.  
 
You have been asked to pay a $85 copayment for out-of-network specialist office visits. The total amount for 
the office visits is $255 ($85 x 3visits = $255). This item/service falls within the out-of-network 
physician/practitioner services/specialist 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 out-of-network specialist office visits provided on October 20, 2021, to December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on September 12, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs $3,628.80. You are being asked to pay $725.76 ($3,628.80 x 20% = 
$725.76). 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 coinsurance for Medicare Part B prescription drugs provided on September 12, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on August 26, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. The Plan 
denied your request. The Plan says the ambulance transport does not meet the Medicare requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee was transported from an acute care facility to a skilled 
nursing facility via stretcher.  The record does not indicate that the enrollee's  clinical condition is such that other methods of transport, such 
as a stretcher van, were contraindicated or that the expertise, services and lifesaving and life-sustaining 
equipment that only a fully equipped ambulance can provide was required. The record also does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0220 and D0230) on September 27, 
2022. 
 
You asked the Plan to pay for the dental services (D0140, D0220 and D0230). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
dental services (D0220 and D0230) has already been exhausted. The dental service (D0140) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 13, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0140, D0220 and D0230) on 
September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595), provided on August 1, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the item was medically necessary. The Plan denied 
your request. The Plan says that the member indicated they did not receive this item. 
 
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. The Plan did not include any documentation of the phone call to the enrollee 
outside of the summary, and the submitted documentation includes an itemized delivery ticket with the 
carriers tracking number and the proof of delivery confirming it was delivered. The Plan hasnt provided 
enough information about why this documentation is not sufficient. Therefore, we decided that the Plan has to 
pay for the electrodes (A4595), provided on August 1, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 21, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford to 
pay this bill. 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 $275 
copayment per day, days 1-5, and a $0 copayment after day 5, each time you are admitted to an acute care 
hospital. 
 
You have been asked to pay a $1375 copayment for the inpatient hospital stay ($275 x 5 days = $1375). This 
item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from September 21, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330), a limited oral evaluation 
(D0140), and an extraction (D7210), provided on September 26, 2022, to September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never informed that the dentist was 
out-of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a panoramic x-ray (D0330), a limited oral evaluation (D0140), and an extraction (D7210), provided 
on September 26, 2022, to September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you felt it was not fair that the Plan says the provider 
is out-of-network even though the provider to you they were in-network. The Plan denied your request. The 
Plan says there is no prior authorization on file for the services provided. 
 
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 September 6, 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 limited oral evaluation (D0140) provided on October 4, 
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 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 March 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from September 12, 2022, to 
September 21, 2022, by an OON provider. 
 
You asked the Plan to pay for physical therapy. You say that you were told the provider was in-network. The 
Plan denied your request. The Plan says you must receive your care from 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 physical therapy provided from September 12, 
2022, to September 21, 2022, by an OON provider.