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

 
We decided that the Plan does not have to pay for the dental services on November 16, 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 December 4, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on November 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Renflexis injection and drug 
administration provided on October 17, 2022. 
 
You asked the Plan to waive the coinsurance for the injection and drug administration. You say that you did not 
know you had this cost sharing amount. 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 drugs and drug administration.  
 
You have been asked to pay $13.35, which is 20% coinsurance of the allowed amount for the drug 
administration ($66.74 allowed amount x 20% coinsurance = $13.35). You have also been asked to pay $68.65, 
which is 20% coinsurance of the allowed amount for the drug administration ($343.24 allowed amount x 20% 
coinsurance = $68.65). You have also been asked to pay $615.04, which is 20% coinsurance of the allowed 
amount for the injection ($3,075.18 allowed amount x 20% coinsurance = $615.04). You have been asked to 
pay a total of $697.04 ($13.35 coinsurance + $68.65 coinsurance + $615.04 coinsurance = $697.04). These items/services fall within the Medicare Part B 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 a Renflexis injection and drug administration provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the depression screening (G0444) and routine exam (G0439), 
provided on November 21, 2022. 
 
You asked the Plan to pay for the depression screening and routine exam. You say that the services should be 
covered. The Plan denied your request. The Plan says you have exhausted the allowed benefit for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that screening for depression is non-covered when 
performed more than one time in a 12-month period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the depression screening and routine exam have not been met. Specifically, records indicate you 
received these services on May 16, 2022. This means your benefits for depression screening have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the depression screening (G0444) and 
routine exam (G0439), provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye examination (92002, 92004) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a medical eye examination with an out-of-network provider. You say that 
the enrollee's vision is worsening, and you want the enrollee to see this provider. The Plan denied your request. 
The Plan says the requested provider is not contracted with the Plan. There are in-network providers that can 
provide the service. 
 
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 
a medical eye examination (92002, 92004) 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 the dental services on November 16, 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 service 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, 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 November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for those patients 
that do not receive adequate relief from traditional conservative methods and do not have instability to indicate 
that fusion is the appropriate treatment. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's body-mass index (BMI) was documented to be 51.24. However, Intracept is 
stated to be not reasonable and necessary and thus not covered by Medicare for patients with a BMI greater 
than 40. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 30, 
2022 to October 31, 2022 
 
You asked the Plan to waive the copayment an office visit. You say that you were told that by the provider that 
the services would be covered. 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 $25 
copayment for each services provided on October 30, 2022 to October 31, 2022. For a total copayment in the 
amount of $50 for both services provided.  
 
You have been asked to pay a $25 copayment for each services provided on October 30, 2022 to October 31, 
2022. For a total copayment in the amount of $50 for both services provided. 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 an office visit provided on October 30, 2022 to 
October 31, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still needs rehabilitation before going 
home to home health the base line has not been met. The Plan denied your request. The Plan says the enrollee's 
records do not show the need for required skilled nursing or skilled rehabilitation services daily which can be 
provided only on an inpatient basis in a skilled nursing facility, medically necessary care may be provided 
safely in a different level of care.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on August 4, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you were not told 
about the facility fee from the doctor's office or the hospital. 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 $325 for 
each non-surgical visit in an outpatient clinic.  
 
You have been asked to pay $136.49 for a hospital outpatient clinic visit. This is less than the standard 
copayment amount. This item/service falls within the non-surgical visit in an outpatient clinic 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 a hospital outpatient clinic visit provided on August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 15, 
2022, to June 19, 2022. 
 
You asked the Plan to waive the copayment for the hospital stay. You say that you would not have gotten the 
surgery if you knew you would be charged this cost sharing amount. 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 $320 
copayment per day for days 1-5 of an in-network inpatient hospital stay. 
 
You have been asked to pay a $320 copayment for days 1-3 of an inpatient hospital stay. You have been asked 
to pay a total of $960 ($320 copayment x 3 days = $960). 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 an inpatient hospital stay from 
June 15, 2022, to June 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator to be provided by an OON provider. You say that the item 
is necessary. The Plan denied your request. The Plan says the requested provider is out-of-network, and there 
are in-network providers that can provide this service. 
 
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 
a home ventilator (E0466) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac computed tomography (CCT) scan with 
coronary calcium scoring. 
 
You asked the Plan to pre-approve the CCT scan. You say that your condition fits Medicare guidelines. The 
Plan denied your request. The Plan says the CCT scan is being used for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CCT scan. Our reviewer says that 
the CCT scan with coronary calcium scoring is not medically necessary. Our physician reviewer found that 
current evidence showing that the use of coronary artery calcium (CAC) scores in clinical management of 
asymptomatic individuals leads to changes in enrollee management or in individual risk behaviors that improve 
cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient support in the peer-reviewed 
literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of 
coronary calcium in guiding optimal management of this enrollee. As such, CT imaging of the heart without 
contrast material with quantitative evaluation of coronary calcium is considered experimental/investigational 
for the evaluation and management of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CCT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac computed tomography (CCT) scan with coronary calcium scoring.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary to continue this service. 
The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you as of 
January 21, 2023, you no longer required skilled therapy or nursing services on a daily inpatient basis and the 
continuation of SNF was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
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 February 12, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM), 
and supplies 
 
You asked the Plan to pre-approve a CGM and supplies. You say that a CGM is medically necessary. The Plan 
denied your request. The Plan says all the required medical criteria for a CGM have not been 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, or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM), and supplies
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 6, 2022, to 
August 9, 2022, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 provided with principal diagnosis code A41.9, described 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 reviewer says that documentation does not support the billed code. 
Our physician reviewer found in this case, there was no clinical or laboratory evidence of sepsis.  
 
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 inpatient hospital services provided on August 6, 2022, to August 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Mis sensor. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 Mis sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 Mis sensor.