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

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on November 16, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service October 5, 2022. Specifically, the 
Plan contract states that one limited oral evaluation is covered per year. You previously received this service on 
October 5, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem 
focused (D0140) provided on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pay for the CGM supplies. 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 enrollee does 
not meet the clinical requirements to be approved. 
 
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 CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103). 
 
You asked the Plan to pre-approve the CGM. 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 enrollee does not 
meet the clinical requirements to be approved. 
 
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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has trouble with processing and 
memory difficulties. The Plan denied your request. The Plan says the records do not show the enrollee has been 
diagnosed with dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that 
the PET scan of the brain is not medically necessary. Our physician reviewer found that the enrollee is noted to 
have a history of concussion/traumatic brain injury. They are not suspected of having either AD or FTD (let 
alone both diagnoses). In as much the basic requirement for coverage of this service would not have been 
met/satisfied at this time. 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that a Freestyle Libre 3 is medically necessary. 
The Plan denied your request. The Plan says a Freestyle Libre 3 is not a covered Medicare item. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested Freestyle Libre 3 is not specified as 
a product that may be classified using code E2103. Therefore, this device is not covered by Medicare at this 
time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 3.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician services provided on September 4, 2022. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the services provided based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for the physician services provided on September 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a synthetic graft (D7995). 
 
You asked the Plan to pre-approve a synthetic graft. You say that you would like this service pre-approved. 
The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a synthetic graft 
(D7995).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 January 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you have been hospitalized several times 
for your condition. The Plan denied your request. The Plan says there is no documentation that criteria has been 
met. 
 
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 the SSBCI benefits have been met. 
Specifically, medical records had been requested but were not received. Therefore, we decided that the Plan 
does not have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the personal care assistance (PCA) services 
 
You asked the Plan to pre-approve the PCA services. You say that the requested services are medically 
necessary to help you bathe yourself. The Plan denied your request. The Plan says the requested services are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCA services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the personal 
care assistance (PCA) services
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 20, 2022. 
 
You asked the Plan to pay for lab services. You say that the claim needs to be reprocessed for payment. 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. 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 lab services provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 19, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the facility is responsible for 
obtaining prior authorization. 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 domiciliary or rest home 
visit provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on August 
22, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the facility is responsible for 
obtaining prior authorization. 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 subsequent nursing 
facility care visit provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital or ambulatory surgical center call (D9420) 
provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a hospital 
or ambulatory surgical center call (D9420) provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 15, 
2022. 
 
You asked the Plan to pay for the dental services. 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 the benefit for the requested item or service was exhausted on date of service August 10, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 23, 
2022 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 
copayment 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 $250 
copayment for ground ambulance services.  
 
 You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on August 23, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on June 30, 2022. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that the claim needs to be reprocessed. 
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. 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 duplex scan of extremity veins provided on June 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for cataract surgery provided on October 27, 
2022. 
 
You asked the Plan to reduce the cost share for cataract surgery. You say that you were told your copayment 
was $240. 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 outpatient surgery.  
 
You have been asked to pay $638.79, which is 20% coinsurance of the allowed amount for cataract surgery 
($3,193.97 allowed amount x 20% coinsurance = $638.79). This item/service falls within the outpatient surgery 
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 reduce the cost share for cataract surgery provided on 
October 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from July 8, 2022, to July 20, 
2022. 
 
You asked the Plan to pay for medical 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. 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 July 7, 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 medical services provided 
from July 8, 2022, to July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve an acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
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 you are medically stable with no acute medical problems and no acute rehabilitation 
nursing needs are identified or documented. The documentation does not support the necessity for admission to an IRF, and the complexity of your therapy 
and medical needs does not require an IRF stay with an interdisciplinary approach to rehabilitative care. While 
you may benefit from physical therapy and/or occupational therapy, your rehabilitation needs can be provided 
in a lower intensity and alternate setting such as in-home with services. 
 
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 an IRF admission and services.