Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided from 
June 1, 2022, to August 19, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayments 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 $30 
copayment per visit for outpatient diagnostic tests/Medicare-covered outpatient diagnostic tests.  
 
You have been asked to pay a $30 copayment per visit for outpatient diagnostic tests. The total amount you are 
being asked to pay is $1,020 ($30 x 34 =$1,020). This item/service falls within the outpatient diagnostic 
tests/Medicare-covered outpatient diagnostic tests 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 outpatient diagnostic tests provided from June 1, 2022, to August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on September 22, 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 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. 
 
 
  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 05/10/2017. Therefore, we 
decided that the Plan does not have to pay for a dental crown (D2740) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) Tooth # 3, 5, 6, 7, 10, 11, 12, 15, 20, 22, 23, 26, 27, 29 and abutment supported porcelain/ceramic 
crown (D6058) for Tooth # 3, 5, 6, 7, 10, 11, 12, 15, 20, 22, 23, 26, 27, 29. 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested services 
approved. The Plan denied your request. The Plan says these services are not covered under your 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. Custom fabricated abutment  
includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not covered under 
the Plans dental benefits. 
 
  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 pre-approve 
custom fabricated abutment  includes placement (D6057) Tooth # 3, 5, 6, 7, 10, 11, 12, 15, 20, 22, 23, 26, 27, 
29 and abutment supported porcelain/ceramic crown (D6058) for Tooth # 3, 5, 6, 7, 10, 11, 12, 15, 20, 22, 23, 
26, 27, 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite filling (D2391) provided on July 
27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were told the enrollee's OON benefits were 
extended. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. The Plan also says they did not find any 
record of incorrect information about OON benefits being provided. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite filling (D2391) provided on July 27, 2022, by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on October 28, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. 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 skilled nursing facility 
care provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
(E0240).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 30, 2022, to July 6, 
2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that acute inpatient hospital services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 30, 2022, to July 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor Kit. 
 
You asked the Plan to pre-approve Freestyle Libre 2 Sensor Kit. You say that the provided records support the 
necessity of the requested service. The Plan denied your request. The Plan says the records do not support that 
you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre 2 Sensor Kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
system (receiver, transmitter, and sensor). 
 
You asked the Plan to pre-approve a CGM system. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the patient requires frequent daily 
adjustments of insulin based on the blood glucose testing result. 
 
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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) system 
(receiver, transmitter, and sensor).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility stay provided on August 11, 2022, 
to August 24, 2022. 
 
You asked the Plan to pay for a skilled nursing facility stay. You say that you needed to be here after your 
surgery, and need the plan to pay. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
stay provided on August 11, 2022, to August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on August 11, 
2022. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you are on a fixed income 
and cannot afford the copayment. 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 $350 
copayment for outpatient procedures and services performed in an outpatient hospital or ambulatory surgical 
center. 
 
You have been asked to pay a $350 copayment for the cataract surgery. This item/service falls within the 
outpatient procedures and services performed in an outpatient hospital or ambulatory surgical center 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 the cataract surgery provided on August 11, 
2022.
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 yo0u are leaving the hospital and you need inpatient 
rehabilitation. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 were admitted to the hospital with an orbital fracture and nasal bone fracture and auricular hematoma after an altercation. The record shows you can ambulate 100 feet with a walker and 
perform transfers with contact guard assistance. The complexity of your nursing medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You have not had an acute change in your neurological status and does not require the intensity of 
rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. You do not require 
rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy management 
or bowel and bladder management. Your medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a onetouch verio test strip 
 
You asked the Plan to pay for the onetouch verio test strip. 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 meet the clinical requirements to be approved, coverage for blood glucose strips and monitors is limited to 
Freestyle and Precision brands produced by Abbott Labs. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the onetouch verio test strip have not been met. 
Therefore, we decided that the Plan does not have to pay for a onetouch verio test strip
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 the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nurse practitioner visit provided on May 17, 2022, to 
May 27, 2022. 
 
You asked the Plan to pay for the nurse practitioner visit. You say that this nurse practitioner is your primary 
care provider. 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). This nurse practitioner left the Plan and you now have a different assigned primary 
care provider. Therefore, we decided that the Plan does not have to pay for the nurse practitioner visit provided 
on May 17, 2022, to May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is the most appropriate setting for intensive 
therapy services and a comprehensive wound care regimen with the goal of optimizing the enrollee's condition 
and facilitating future hip surgery. You say that the enrollee requires intensive inpatient rehabilitation with 
daily physician management and their needs cannot be met by a skilled nursing facility or home health at this 
time. The Plan denied your request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require rehabilitation nursing or treatment by multiple 
therapies. Although the enrollee had a functional decline from their baseline level of function and would 
benefit from occupational and physical therapy, they do not require the intensity of therapies provided in acute 
inpatient rehabilitation. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services on 
September 14, 2022, to October 05, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health services. You say that you want to 
appeal the amount being charged. 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 $350 
copayment per day for days 1-5 and $0 after day 5 each time you are admitted to a psychiatric hospital. You 
have a maximum inpatient mental health benefit of 190 days per lifetime. Covered services include mental 
health care services that require a hospital stay. 5 x $350 = $1,750. Therefore, results in the total cost sharing 
amount of $1,750.  
 
 You have been asked to pay a $350 copayment per day for inpatient mental health services. This item/service 
falls within the Inpatient mental health 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 inpatient mental health services on September 14, 2022, to October 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on August 31, 2022. 
 
You asked the Plan to pay for the complete upper and lower dentures. You say that you would like to be 
reimbursed for the dentures. The Plan denied your request. The Plan says dentures are not covered under your 
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 the 
complete upper denture (D5110) and complete lower denture (D5120) provided on August 31, 2022.