Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the admission is not 
deemed medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 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 
the Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI).. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 magnetic resonance imaging (MRI).. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI of the lumbar spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI). have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle 14 day sensor. 
 
You asked the Plan to pre-approve the Freestyle 14 day 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 
the Freestyle 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle 14 day sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are being charged $220 because you tried to 
get your records from the previous dentist. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service September 20, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and panoramic radiographic image (D0330) provided on November 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on October 18, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records show that 19 drug 
classes were tested, including Amphetamines, Benzodizepines, Buprenorphine, Cannabinoids-natural, Cocaine, 
Fentanyls, Gabapentin-non-blood, Heroin metabolite, Methadone, Methylenedioxyamphetamines, 
Methylphenidate, Opiates, Opioids and opiate analogs, Oxycodone, Phencyclidine, Pregabalin, Skeletal muscle 
relaxants, Tapentadol, and Tramadol. Based on this information, we decided that Medicare rules for coverage 
of procedure code G0482 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0482 provided on October 18, 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 for an intraoral x-ray (D0210) provided on October 25, 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 an 
intraoral x-ray (D0210) provided on October 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that 
unfortunately during the medical assistance, before my mother could be transferred to the hospital she passed 
away. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastroesophageal reflux test (91035) and 
esophagogastroduodenoscopy (EGD) (43239). 
 
You asked the Plan to pre-approve a gastroesophageal reflux test and esophagogastroduodenoscopy. The Plan 
denied your request. The Plan says the records do not support that the enrollee has upper gastrointestinal 
symptoms or suspected gastric reflux. The Plan also says the enrollee does not have diagnostic problems 
associated with atypical symptoms, and has not undergone conventional testing for gastric reflux. 
 
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 a gastroesophageal reflux test and 
esophagogastroduodenoscopy. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has historically had 
Helicobacter pylori (H. pylori) peptic disease, and may have gastroesophageal reflux disease (GERD) which is 
well controlled by ongoing proton pump inhibitor (PPI) use. The available records support that the enrollee has 
undergone at least three EGD studies over the 3-year period between December 2018, and November 2021. 
Our reviewer found that the documentation provided shows the enrollee's gastrointestinal review of systems is 
presently negative for upper gastrointestinal complaints, and that their last endoscopy documented neither ulcer 
persistence, active H. pylori, nor red flag conditions such as Barrett's or gastric intestinal metaplasia that 
require surveillance. Our physician reviewer also found that the available records do not support the medical 
necessity nor appropriateness of a repeat EGD for the enrollee at this time, nor of the proposed Bravo pH (a 
measure of the acidity or alkalinity of a fluid) monitoring while on PPI therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a gastroesophageal reflux test and esophagogastroduodenoscopy have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a gastroesophageal reflux test (91035) 
and esophagogastroduodenoscopy (EGD) (43239).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on October 12, 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 
endodontic therapy (D3330) provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine dental cleaning (D1110) provided on September 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you require additional cleanings each year due 
to a buildup on your teeth. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 11, 2022. Therefore, 
we decided that the Plan does not have to pay for a routine dental cleaning (D1110) provided on September 15, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says this request 
does not meet the Medicare or health plan coverage criteria. 
 
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 a SPECT scan. Our reviewer says that a 
single-photon emission computerized tomography (SPECT) scan (78803) is not medically reasonable and 
necessary in this case. Our physician reviewer found prostate-specific membrane antigen (PSMA) or Auxumin 
positron emission tomography (PET)/computed tomography (CT) may be indicated for rising prostate-specific 
antigen (PSA) in the setting of prostate cancer restaging. The American Urological Association 
(AUA)/American Society for Therapeutic Radiology and Oncology (ASTRO) guidelines do not include a 
SPECT CT for restaging of prostate cancer. Our reviewer found that similarly, the National Comprehensive 
Cancer Network (NCCN) guidelines do not indicate a role for SPECT CT in the workup, restaging, or 
surveillance of prostate cancer. Per the SPECT CT National Coverage Determination (NCD), there is no 
specific role for this modality for prostate cancer restaging. Our physician reviewer also found that based on 
the additional information available, the request does not meet the Medicare or health plan coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78803).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance imaging (MRI) procedure (76498) provided on 
June 30, 2022. 
 
You asked the Plan to pay for the MRI procedure. You say that this procedure was performed out of necessity 
to best treat the enrollee. You also say that you believe the provided information warrants a reversal of the 
denial and subsequent payment of this claim. The Plan denied your request. The Plan says that this service is 
not on the Medicare Fee Schedule. 
 
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. The records do not support the Plan's denial of payment in this case. This means 
that the Plan has not provided a valid reason for denying payment of the MRI procedure. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the magnetic resonance imaging 
(MRI) procedure (76498) provided on June 30, 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: Drugs
Decision: Favorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the drug. You say that this was medically necessary. The Plan denied your 
request. The Plan says step therapy guidelines were not followed. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
The requested medication is not a new prescription, as it was last used less than a year ago, in April 2022. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9945) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that your occlusal guard is necessary, to keep you 
from grinding your teeth and damaging your partial crowns. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental 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. 
 
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 
occlusal guard (D9945) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic 
radiographic image (D0330) provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see a new provider because your 
prior dentures did not fit right. The Plan denied your request. The Plan says your benefit for the requested items 
or services 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 items or services was exhausted on the date of service of June 2, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
panoramic radiographic image (D0330) provided on November 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 1, 2022, to 
July 1, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware of the copayment 
for the SNF stay and would have discharged sooner if you were informed. 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 $0 
copayment per day for days 1-20 and a $188 copayment per day for days 21-100 for Medicare-covered skilled 
nursing facility care.  
 
 
  You have been asked to pay total copayment of $1,880 for a SNF stay ($188 per day x 10 days = $1,880). This 
item/service falls within the Medicare-covered skilled nursing facility care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a SNF stay provided from June 1, 2022, to July 1, 2022.  
 
Your complaint about not being informed of a copayment for your SNF stay is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.