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

 
We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve CGM sensor. You say that the CGM sensor is needed for the enrollee due to 
medical complexity. 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 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
continuous glucose monitor (CGM) sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left hip magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says there has not been 
failure of conservative treatment. 
 
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 an MRI. Our physician reviewer found 
that the enrollee has chronic pain. The record does not indicate the presence of red flag signs or symptoms, the 
failure of conservative treatment, or that plain x-rays are non-diagnostic. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve left hip magnetic resonance imaging (MRI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve a computerized tomography (CT) scan. You say that the services requested 
are medically necessary. 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 CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computerized tomography (CT) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided 
records do not indicate that the requested test was intended to be ordered and does not support the medical 
necessity or reasonableness, as defined by Medicare rules, of the requested service. 
 
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 computerized tomography (CT) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), prophylaxis (D1110), and resin-based composite (D2335) provided on October 4, 2022, and October 
13, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that prior to receiving these services you called and 
were advised that they accepted your insurance, and the Plan would pay 50% of the bill. 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 that you contacted the Plan prior to these dates of service to 
verify benefits and provider eligibility, and no incorrect information was provided on these calls. 
 
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 comprehensive oral evaluation (D0150), bitewing x-rays (D0274), prophylaxis (D1110), and 
resin-based composite (D2335) provided on October 4, 2022, and October 13, 2022, by an out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on July 19, 2021. 
 
You asked the Plan to pay for the office visit. You say that you received a letter stating that no authorization 
was required. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 office visit. Our reviewer says that the 
records indicate that the care provided was medically necessary. Our physician reviewer found the enrollee 
presented with a cough and was given a COVID-19 PCR test. It would not have been medically reasonable to 
delay the 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 office visit have been met. Therefore, we decided that the Plan has to pay 
for an office visit provided on July 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 enrollee is receiving the 
inappropriate level of care needed at the current facility. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an long term acute 
care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on 
August 2, 2022, and August 24, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy services. You say that you cannot afford all the 
bills that are being sent to you for the services received. 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 for Medicare Part B 
chemotherapy drugs and administration the enrollees must pay 20% of the total cost for Medicare-covered 
drugs and administration.  
 
  You have been asked to pay up to 20% coinsurance for chemotherapy services. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
August 2, 2022 Administration of 
drug 
$385.78 20% $77.16 
August 2, 2022 Chemotherapy drug $7,770.40 20%  $1,445.7 
billed less than 20% 
August 24, 2022 IV Therapy $96.84 20% $19.37 
August 24, 2022 Administration of 
drug 
$385.78 20% $77.16 
TOTAL:    $1,619.45 
  
Chemotherapy services falls within the Medicare Part B prescription drugs 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 coinsurance for pembrolizumab injection and administration provided on August 2, 
2022, and August 24, 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. The Plan denied your request. The Plan says the Plan 
will continue to cover medically necessary acute and critical care at the current facility until the enrollee's 
condition is stable for transfer to an alternate level of care, a skilled nursing facility, or until the clinical 
circumstances change such that LTACH may be reconsidered. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for radiation therapy, lab work, and a specialist 
office visit provided on July 12, 2022, to August 30, 2022. 
 
You asked the Plan to waive the cost share for radiation therapy, lab work, and a specialist office visit. You say 
that you are disputing the share cost. 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 20% 
coinsurance and $5 for outpatient diagnostic tests and therapeutic services and supplies and $40 copayment for 
Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay 20% coinsurance for radiation therapy, $5 for lab work, and $40 for a specialist 
office visit. This items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
and Physician/Practitioner services, including doctor's office visits benefit categories. 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 share for radiation therapy, lab work, and a specialist office visit provided on 
July 12, 2022, to August 30, 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. The Plan denied your request. The Plan says 
medically necessary care may be provided safely in a different level of care. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
 
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: 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. You say that the SNF care is not medically necessary, and the 
enrollee's needs can be met in an assisted living facility with home health services, long-term care with part-
time skilled services, home health services, and part-time skilled services. The Plan denied your request. The 
Plan says the enrollee is not safe to return home currently. 
  
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you need to have surgery on your jaw. The 
Plan denied your request. The Plan says your benefit only allows 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
 The file shows that routine transportation over 50 miles was requested. We looked at your request, the records 
in the case file, and the rules. Your benefit only covers routine transportation for up to 50 miles. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and exam with an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an office visit and exam with an oral surgeon.
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 enrollee's current 
functional level, inpatient daily skilled services in a skilled nursing facility are not necessary, but further 
services for the goal of continued rehabilitation can be safely delivered in a long term care facility, home or in 
an outpatient setting. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 group 3 power wheelchair with a single power option. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
enrollee does not have a need for a power tilt option. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that a group 3 power wheelchair with a power tilt option has been requested. 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 requested wheelchair. Our physician reviewer found 
that the enrollee has a history of a stroke with left-sided weakness and mobility impairment.  The provided 
records do not support that the enrollee is high risk for skin breakdown. She walks short distances with a 
walker. She does not have a history of pressure ulcer(s) or have had skin flap surgery. The records do not 
document that she performs bladder self-catheterization or that she has increased muscle tone or spasticity. 
Therefore, the coverage criteria have not been met. 
 
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 requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair with a single power option.
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 enrollee has no social/family support 
and stable for transfer to LTACH. The Plan denied your request. The Plan says the enrollee does not have 
clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has improved medically and may safely receive further care at the 
current acute care hospital or a lower level of care when deemed appropriate. 
 
 
 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.