Persius/hicric huggingface dataset:
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 CGM. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of CGM have been met. Supporting 
medical records were not submitted by your treating physician. The Plan requested records but none were 
provided. Without medical records, we cannot determine whether you meet criteria for a CGM at this time. 
Supporting medical records should be submitted to the Plan for review. 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 urgent care visit provided on August 19, 
2022. 
 
You asked the Plan to waive the copayment for urgent care 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 $60 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for urgent care visit. This item/service falls within the urgently 
needed services 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 urgent care visit provided 
on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 15, 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 August 15, 
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 the dental services on September 19, 2022, to October 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered 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 dental 
services on September 19, 2022, to October 6, 2022.
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 CGM. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of CGM have been met. Your treating 
physician has not submitted any supporting medical records to the Plan. The Plan attempted to obtain medical 
records, but none were submitted. Without medical records, we cannot determine whether you may meet 
criteria for a CGM at this time. Medical records should be submitted to the Plan to support your request. 
Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor 
(CGM).
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 the services are medically necessary for 
the enrollee to receive the medical care and supervision needed for their conditions. The Plan denied your 
request. The Plan says the enrollee can remain in the current acute care location until no further acute level care 
is needed. 
 
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 currently still unstable with the current treatment regimen 
and requires short-term additional acute care services that can safely be administered at the current facility until 
more stable for transfer. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on September 12, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were approved which gave 
the doctors and hospital the go-ahead to do the catheterization anywhere between August 31, 2022, and 
October 15, 2022. The Plan denied your request. The Plan says self-administered drugs are not covered under 
your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on September 12, 2022.  
 
  Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 8, 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 prior 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 August 8, 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 an arthrocentesis, fluoroscopic guidance for needle 
placement, injection for hip x-ray, a methylprednisolone injection, and low osmolar contrast material provided 
on August 25, 2022, by an OON provider. 
 
You asked the Plan to pay for an arthrocentesis, fluoroscopic guidance for needle placement, injection for hip 
x-ray, a methylprednisolone injection, and low osmolar contrast material. You say that the procedures do not 
require authorization. The Plan denied your request. The Plan says the enroll 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 an arthrocentesis, fluoroscopic guidance for needle 
placement, injection for hip x-ray, a methylprednisolone injection, and low osmolar contrast material provided 
on August 25, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 12, 2022. 
 
You asked the Plan to pay for the dental services. 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 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 September 19, 2022, and 
September 28, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on 
October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator provided on September 16, 
2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you were informed that you 
would be reimbursed for the equipment. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the portable oxygen 
concentrator provided on September 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on July 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you cannot 
afford the ambulance bill. You also say that you would like to request a one-time waiver of this fee because 
you did not personally request services from the paramedics, and you did not require hospitalization or further 
treatment. The Plan denied your request. The Plan says Medicare will not pay for ambulance response and 
treatment without transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on July 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the admission date for the NOA as required. Based on this information, we find that the 
Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from August 14, 2022, to September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spinal Cord Stimulator. 
 You asked the Plan to pre-approve a Spinal Cord Stimulator. You say that the service is medically necessary 
The Plan denied your request. The Plan says the service is not medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that performance and documentation of an effective trial 
is a prerequisite for permanent nerve stimulation. 
 
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 Spinal Cord Stimulator. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found a 20% improvement in pain 
score is not considered a positive trial. 
 
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 Spinal Cord Stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Spinal Cord Stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 3, 2021, 
to October 6, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
providers statement about the enrollee's condition is sufficient. The Plan denied your request. The Plan says the 
diagnosis is not consistent with the documentation received. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code A41.9, defined as sepsis, unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee presented to the emergency department 
(ED) with abdominal pain following an esophagogastroduodenoscopy (EGD) and colonoscopy procedure. The 
enrollee's platelets remained above 150,000 per microliter, creatinine remained below 1.2mg/dl and the total 
bilirubin below 1.2mg/dl after treatment in the ED and through the hospital stay. There was no clinical or 
laboratory evidence of sepsis. The review has determined that the documentation did not support diagnosis 
code A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on October 3, 2021, to October 6, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 03, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are disputing the share 
cost. 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 for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay a $275 copayment for outpatient surgery. This item/service falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 outpatient surgery 
provided on June 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on July 22, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. 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 July 22, 2020.
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. The Plan denied your request. The Plan says medically necessary 
care may be provided safely in a different level of care. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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.