Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the health plan has covered their Libre kits without 
requirements since you became active on your Plan. The Plan denied your request. The Plan says the Medicare 
rules 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. You do not take insulin, and do not adjust an insulin dose based on 
your blood glucose results. 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 FreeStyle Libre 2 CGM.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission services provided from February 1, 
2022, to February 6, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient admission services. You say that admission was requested and 
approved by the Plan. You also say that the enrollee did meet the criteria for admission. The Plan denied your 
request. The Plan says services from non-participating providers are not covered unless pre-authorized. 
 
 
 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 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 the inpatient admission services provided from 
February 1, 2022, to February 6, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Triage testing provided on December 2, 2021. 
 
You asked the Plan to pay for the CxBladder Triage testing. You say that this is a medically necessary test. The 
Plan denied your request. The Plan says this is noncovered screening testing. 
 
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 pay for the CxBladder Triage testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. The most recent American Urological Association (AUA) guidelines state that "Clinicians 
should not use urine cytology or urine-based tumor markers in the initial evaluation of patients with 
microhematuria."   
 
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 CxBladder Triage testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the CxBladder Triage testing provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 22, 2022, to March 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee developed a bed 
sore from negligence and had to stay longer than expected. The Plan denied your request. The Plan says the 
enrollee has been charged the correct cost sharing 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 $365 per day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that the enrollee was in the hospital from February 22, 2022, to March 4, 2022. Therefore, the 
enrollee has been asked to pay $365 per day for days 1-5 of inpatient care. The total for the stay is $1,825 
($365 copayment x 5 days = $1,825). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided 
from February 22, 2022, to March 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography, a screening digital breast 
tomosynthesis, and a dual-energy X-ray absorptiometry (DXA) of the axial skeleton provided on January 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a screening mammography, a screening digital breast tomosynthesis, and a dual-
energy X-ray absorptiometry (DXA) of the axial skeleton. You say that this procedure was medically necessary 
as the patient went to primary care physician and had a wellness visit where they ordered the mammogram and 
bone density test. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 a screening mammography, a screening digital 
breast tomosynthesis, and a dual-energy X-ray absorptiometry (DXA) of the axial skeleton provided on January 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 8, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware an authorization was needed for 
office visits. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized and a valid authorization was not found on file. 
 
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 the office visit provided on March 8, 2022, by an 
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81442) provided on December 
17, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that LCA A58795 provides a list of non-covered CPT 
codes.  
 
We looked at the file and Medicare rules. Per A58795, the billed CPT code, 81442, is not covered. Based on 
this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services (81442) provided on December 17, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence that this is an integral part of a brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(CPT code E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that the heavy-duty hospital bed is medically 
necessary for the patient and will benefit from it. The Plan denied your request. The Plan says the Medicare 
rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the hospital bed have not been met. Your request is not a covered 
benefit because the enrollee's records show they do not have body weight between 350 and 600 pounds. 
Therefore, we decided that the Plan does not have to pre-approve the hospital bed, heavy duty, extra wide, with 
weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with 
mattress (CPT code E0303).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 23, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says it is not responsible for this bill because the 
member was on hospice on the date of service. 
 
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 medical services provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws (D0367), a surgical removal of an implant body (D6100), an 
extraction (D7210), a bone replacement graft for ridge preservation (D7953), intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia  each 
subsequent 15 minute increment (D9243) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the requested dental services. You say that you have been waiting for a year 
to get these dental services done. You also say this began as a simple extraction that now has caused other 
issues. Your mouth gums are open, and you have a bad infection. When you speak for too long, your mouth 
bleeds and you are in excruciating pain. The Plan denied your request. The Plan says any procedure code not 
listed is not a covered benefit with your Plan. The Plan also says you must see an in-network provider to 
receive services. There are in-network dental providers available. 
 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 cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367), a 
surgical removal of an implant body (D6100), an extraction (D7210), a bone replacement graft for ridge 
preservation (D7953), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and 
intravenous moderate (conscious) sedation/analgesia  each subsequent 15 minute increment (D9243) to be 
provided by an out-of-network (OON) provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met at a lower level of 
care. The Plan denied your request. The Plan says that the member's nursing, medical management and 
rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for obstructive uropathy 
and acute renal failure. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removable prosthodontic procedure (D5899 x 2) provided 
on January 21, 2022. 
 
You asked the Plan to pay for removable prosthodontic procedure. You say that your agent told you dentures 
were covered. The Plan denied your request. The Plan says a removable prosthodontic procedure (D5899) is 
not covered by your supplemental 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 
removable prosthodontic procedure (D5899 x 2) provided on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D9310, D0230, D0364) provided from 
March 10, 2022, to March 14, 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 and some services were rendered by an out-of-network provider, therefore, the 
coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are 
responsible for the difference between the INFS and dentists' charged fees when visiting an out-of-network 
dentist, as indicated in your Evidence of Coverage on page 92. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 dental 
services (D9310, D0230, D0364) provided from March 10, 2022, to March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210) provided on January 12, 2022. 
 
You asked the Plan to pay for the extractions (D7210). You say that the referenced claim was of strict medical 
necessity to alleviate and treat severe root infections. You say that medical health necessity will be seen after 
review and reimbursement issued. The Plan denied your request. The Plan says extractions are 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 
extractions (D7210) provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled therapy services (97112) provided December 1, 2021 
to December 13, 2021. 
 
You asked the Plan to pay for the skilled therapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says billing rules were not met and the code billed cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97112 is not supported in the medical record. Specifically, multiple modifiers were 
incorrectly billed. Based on this information, we decided that Medicare rules for coverage of the skilled therapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for skilled therapy 
services (97112) provided December 1, 2021 to December 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 9, 
2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $150 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $150 copayment for the colonoscopy. Colonoscopies fall 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 colonoscopy 
provided on November 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve Enbrel. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Enbrel.  
 
Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.