Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on September 30, 2022. 
 
You asked the Plan to pay for an ultrasound. You say that this was medically necessary and should be covered. 
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 an ultrasound provided 
on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not know why this is not being paid. The 
Plan denied your request. The Plan says your benefit for preventative dental 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 preventative dental benefits has been previously exhausted. Therefore, we decided that 
the Plan does not have to pay for intraoral imaging (D0220) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not 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. 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).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for critical care provided on November 9, 2022. 
 
You asked the Plan to pay for the critical care. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the critical care. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was evaluated out-of-network for intra-abdominal abscess, GI bleed, hepatic 
encephalopathy and acute on chronic liver disease. It would not have been medically reasonable to delay 
services until the enrollee returned to the service area. 
 
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 critical care have been met. Therefore, we decided that the Plan has to pay 
for critical care provided on November 9, 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 pay more for the amalgam (D2150) for tooth #14 provided on 
December 6, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you had a chip on your tooth and the 
service should not have been denied. The Plan denied your request. The Plan says you are responsible for the 
difference in allowed amount and the proper cost share was applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The total allowed amount for the resin-based composite (D2392) was $190.93. The total allowed amount for 
the approved amalgam (D2150) was $134.58. The difference in the allowed amount was $56.35 ($190.93 billed 
service - $134.58 approved service). The deductible of $100 was charged. The total coinsurance amount was 
$17.28 ($34.57 after deductible x 50% coinsurance). The total enrollee responsibility was $173.64 ($56.35 
difference + $100 deductible + $17.28 coinsurance). 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 pay more for the 
amalgam (D2150) for tooth #14 provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the thyrotropin alpha injection, and the 
drug administration provided by an in-network provider on November 14, 2022. 
 You asked the Plan to waive the cost sharing for the injection and the administration. You say that you think 
that these services should 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 20% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer, 
and a 20% coinsurance for in-network Medicare-covered surgery or other services at an outpatient hospital or 
ambulatory surgical center, including but not limited to hospital or other facility charges and physician or 
surgical charges. 
 
You have been asked to pay a $381.39 coinsurance for the injection ($1906.93 allowed amount x .20 = $381.39 
rounded up). This item/service falls within the Medicare Part B prescription drugs benefit category. You have 
also been asked to pay a $2.77 coinsurance for the administration ($13.87 allowed amount x .20 = $2.77). 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 cost sharing 
for the thyrotropin alpha injection, and the drug administration provided by an in-network provider on 
November 14, 2022.
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 necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of 
care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long-term care needs. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from November 13, 
2020, to December 8, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the claim was originally filed with the 
wrong company, and you would like it processed for payment. The Plan denied your request. The Plan says the 
denial for payment is correct because the claim was not filed on time. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
  The record shows that a claim for the skilled nursing services was not filed until July 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the skilled nursing services provided from November 13, 2020, 
to December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on November 23, 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 scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 12, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were unaware that this provider was out-of-
network and needed 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 an office visit provided 
on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, fluoride application, other drugs or medicaments, 
and a crown (D1110, D1206, D9630, D2740) provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your annual $1,500 dental benefit maximum 
allowance 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 20, 2022, 
Therefore, we decided that the Plan does not have to pay for a cleaning, fluoride application, other drugs or 
medicaments, and a crown (D1110, D1206, D9630, D2740) provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 21, 2022. 
 
You asked the Plan to pay for dental services. You say that you are requesting reconsideration. 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 dental services provided 
on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on May 20, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee was in a nursing home and the 
admission authorization should cover these services. 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 wound care supplies 
provided on May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. 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 laboratory services 
provided on April 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency nerve ablation/destruction services 
identified with code 64624. 
 
You asked the Plan to pre-approve radiofrequency nerve ablation/destruction services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA of the genicular nerves is only covered for 
certain indications. 
 
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 radiofrequency nerve 
ablation/destruction services. Our reviewer says that the documentation does not support that the requested 
services are medically reasonable or necessary. Our physician reviewer found you have osteoarthritis of the 
Left knee. You have had steroid injection and viscosupplementation. Your medications include Voltaren gel, 
tylenol and opiates. You underwent diagnostic block of the genicular nerves.  The role of genicular nerve radiofrequency ablation (RFA) is the subject of ongoing clinical trials. It is 
considered an experimental/ investigational. Therefore, you do not meet criteria for the requested 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 radiofrequency nerve ablation/destruction services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency nerve ablation/destruction 
services identified with code 64624.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided on July 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you think the provided services should be 
covered in full. 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. This benefit includes a $1,500 
combined allowance for supplemental preventive and comprehensive dental services every year. Member is 
responsible for any amount over and above the allowance amount. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $516 for date of service, $954 for date of service and $30 for date of service ($516 + $954 
+ $30 =  $1,500), therefore, your benefit was exhausted on date of service July 25, 2022. Therefore, we decided 
that the Plan does not have to pay more for comprehensive oral evaluation - new or established patient (D0150) 
and intraoral - complete series of radiographic images (D0210) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210), unspecified oral surgery 
procedure (D7999) and nitrous oxide (D9230) provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need an explanation of why this claim was 
denied. 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 dental services was exhausted prior to this date of service. Therefore, we decided that 
the Plan does not have to pay for a surgical extraction (D7210), unspecified oral surgery procedure (D7999) 
and nitrous oxide (D9230) provided on November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and to pay more for the extractions 
(D7140 and D7210) for tooth #3, #4, #5, and #6 provided on January 7, 2022, and February 23, 2022. 
 You asked the Plan to pay for the dental services. You say that the dentist office told you that the services 
would be covered. The Plan denied your request. The Plan says the correct cost sharing was applied. Also, the 
denial of payment for the core buildup is correct because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The total allowed amount for the first extractions was $145 with a coinsurance amount of $72.50 ($145 total x 
50% coinsurance). The total amount for the second extractions was $114 with a coinsurance amount of $57 
($114 total x 50% coinsurance). You have been asked to pay a 50% coinsurance amount for the extractions. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The core buildup 
is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the 
core buildup (D2950) and to pay more for the extractions (D7140 and D7210) for tooth #3, #4, #5, and #6 
provided on January 7, 2022, and February 23, 2022.