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

 
We decided that the Plan has to pay for the filling (D2331) provided on October 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that your filling fell out of your tooth. You say that 
you cannot help that the dentist you saw almost 2 years ago did bad work. You also say that it has been 1 year 
and 10 months since your last filling. The Plan denied your request. The Plan says that the claim was processed 
correctly. 
 
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. Specifically, the file does not contain information that substantiates that the 
service denied correctly. The provided documentation does not show the specific tooth the filling was 
performed for on the date of service in this case. Consequently, it cannot be determined if the frequency limit 
has been exceeded. Therefore, we decided that the Plan has to pay for the filling (D2331) provided on October 
7, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fiberscopic laryngoscopy provided on 
July 2, 2021. 
 
You asked the Plan to waive the copayment for the fiberscopic laryngoscopy. You say that you were not told 
there would be a copayment for this procedure. The Plan denied your request. The Plan says the proper 
copayment was applied for the procedure. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient procedures and services.  
 
  You have been asked to pay a $100 copayment for the fiberscopic laryngoscopy. The fiberscopic laryngoscopy 
falls within the Outpatient hospital 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 a fiberscopic laryngoscopy provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an interrogation device evaluation provided 
on August 18, 2021. 
 
You asked the Plan to waive the copayment for an interrogation device evaluation. You say that you disagree 
with the charges because you performed the test yourself on the member. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $5 copayment for outpatient diagnostic tests. 
 
An interrogation device evaluation is considered an outpatient diagnostic test. Therefore, the enrollee is 
responsible to pay the $5 copayment.   The enrollee has been asked to pay a $5 copayment for an interrogation device evaluation. An interrogation 
device evaluation falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an interrogation device 
evaluation provided on August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 11, 2022. 
 
You asked the Plan to pre-approve SNF care after March 11, 2022. You say that the requested admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is 
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 after March 11, 2022. Our 
reviewer says that daily skilled services are not necessary. 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 after March 11, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on October 22, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital for a 
procedure. You say that you feel this service should be included in the hospital stay. You also say that these 
medications were given to you by the hospital. The Plan denied your request. The Plan says the medications 
you received are considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the medications you received are not covered under 
Medicare Part B. 
 
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 in an outpatient setting on October 22, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show that the cause of the enrollee's symptoms is 
from elevated left atrial pressure. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. CardioMEMS is 
being requested for management of congestive heart failure (CHF) in this patient. The CardioMEMS device 
was approved by the Food & Drug Administration (FDA) in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with CHF. 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. At this time the CardioMEMS system 
would not be considered medically appropriate and necessary in this patients clinical management. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 
enrollee may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo 2mg tablets. 
 
You asked the Plan to pre-approve Livalo 2mg tablets. You say that you believe that the continuation of this 
medication at this time is appropriate and medically necessary. The Plan denied your request. The Plan says 
Livalo is a self-administered drug that does not fall under Part B coverage. 
 
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 pre-approve Livalo 2mg tablets.  
 
 
 
  
Benefits for Livalo 2mg tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgery provided by on November 4, 
2021. 
 
You asked the Plan to waive the copayment for the surgery. You say that the copayment should be waived 
because it should of been when you were an inpatient. The Plan denied your request. The Plan says the proper 
copayment was applied for this service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Medicare-covered in-network outpatient surgery services.  
 
  You have been asked to pay a $350 copayment for the surgery. The surgery falls within Outpatient surgery, 
including 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 a surgery provided by on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) purchased on January 
17, 2020. 
 
You asked the Plan to pay for the 2020 gym membership. You say that you weren't able to get your bill due to 
the pandemic, and the gym was closed for part of the year as well. The Plan denied your request. The Plan says 
you did not submit your reimbursement request within the required time frame. All reimbursement requests 
must be received no later than March 31st of the following year. You are responsible for any reimbursement 
requests received outside of this coverage year. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $150 per calendar year. Reimbursement requests must be received no later than March 31st of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because the request for reimbursement of 
health and wellness services purchased in 2020 was not received until November 2021. Therefore, we decided 
that the Plan does not have to pay for the health club membership (S9970) purchased on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission. 
 
You asked the Plan to pre-approve an inpatient psychiatric admission. You say that the inpatient psychiatric 
admission is medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, the 
request is not medically necessary because the records received show you were able to participate in your daily 
activities, had no hallucinations and were cooperative in taking your medicines with a plan to improve your 
life. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 an inpatient psychiatric admission. Our 
reviewer says that an inpatient psychiatric admission is not medically necessary. Our physician reviewer found 
that based upon review the records provided it was not expected this enrollee would improve in a reasonable 
period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions 
and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have 
dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. 
The health Plans denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to 
require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and 
compliant. It did not appear that active treatment was taking place. It did not appear that the services were 
reasonably expected to improve the enrollees condition or for the purpose of diagnosis. I am unable to find an 
individualized treatment plan however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review the records provided for the admission of this 
enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a 
danger to himself or others, no auditory or visual hallucinations. He is noted to be cooperative and compliant 
with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you currently take insulin 4 times per day 
and test your blood sugar 4 times per day. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for a therapeutic CGM. 
 
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 does not indicate that you 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 therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor 
(CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request cannot be approved at this time. 
 
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 improving gradually, alert, and more stable and should 
require only short-term additional acute care services that can safely be administered at the current facility. The 
enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered 
when the treatment is complete.  
 
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 admission to a long-term acute care hospital (LTACH).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes show that the lung nodule has resolved. 
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the resolved left lower 
lobe nodule is not in need of a follow-up. However, the report of 11/8/21 described new reticular nodular 
process in the right lower lobe of uncertain significance, but new since the CT of 8/29/21. Follow-up of this 
process in the right lower lobe is reasonable and indicated.  
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) of the chest for the enrollee.  
 
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.