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

 
We decided that the Plan does not have to pre-approve a CGM and related supplies 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies 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. 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 and related supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CGM and related supplies
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 the enrollee requires daily physician oversight to 
actively manage medical conditions to optimize recovery and avoid re-hospitalization. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee can receive the care they 
need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 29, 
2022, to May 2, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were admitted to 
the hospital sooner than 24 hours after a previous stay. 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 $225 
copayment per day for days 1-6 for each inpatient hospital stay.  
 
According to the EOC, a cost share applies to each inpatient admission. You have been asked to pay $675 for 
the inpatient hospital stay, which is a $225 copayment each day ($225 copayment per day x 3 days = $675). 
This item/service falls within the inpatient hospital 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 an inpatient hospital stay from April 29, 2022, to May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF services to 
optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 12, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the services you were provided was 
very short and you should not be charged 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 an office visit provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on October 
04, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that there is no authorization 
required for the services provided. 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 subsequent nursing 
facility care visit provided on October 04, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided from September 9, 
2022, to September 28, 2022, by an out-of-network (OON) provider. 
   
You asked the Plan to pay for subsequent nursing facility care. You say that due to the enrollee's health issues 
they are unable to obtain an authorization for themselves. The Plan denied your request. The Plan says 
authorization for out of network services was not received. 
 
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 subsequent nursing facility care provided on 
September 9, 2022, to September 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abdominal paracentesis provided on August 15, 2022. 
 
You asked the Plan to pay for abdominal paracentesis. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 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 abdominal paracentesis provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #6 and #8, a pontic 
(D6245) for tooth #7, core buildup (D2950) for tooth #6 and #8, desensitizing medicament (D9910) for tooth 
#6 and #8, and gingival irrigation (D4921) for Q10. 
 
You asked the Plan to pre-approve the dental services. You say that you had the root canals done in preparation 
for the bridge and you now need the crown. The Plan denied your request. The Plan says the requested services 
would not restore function to your mouth correctly. 
 
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 covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that based on the submitted documentation the requested services would not be considered necessary. Our physician reviewer found the Plan allows for replacement of a single missing anterior tooth where there are 
no other teeth missing in the arch. In this case, at least tooth #2, #4, #5, and #10 are missing, possibly more in 
the upper left quadrant that cannot be seen in the provided x-rays. The treatment plan accounts for replacing #7, 
but not the other teeth that are missing. Under the Plan provisions, fixed bridges, even those replacing one 
anterior tooth, are not a covered service where there are multiple missing teeth in the arch. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6740) for tooth #6 and #8, a pontic (D6245) for tooth #7, core 
buildup (D2950) for tooth #6 and #8, desensitizing medicament (D9910) for tooth #6 and #8, and gingival 
irrigation (D4921) for Q10.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on August 29, 2022, 
through August 31, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you disagree with the denial and would 
like the plan to reconsider payment. The Plan denied your request. The Plan says Medicare does not pay for 
this service. 
 
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 pay for self-administered drugs provided 
on August 29, 2022, through August 31, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from July 1, 2022, to 
July 12, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you assumed the rehabilitation center 
would be covered by the Plan and you were unaware it was considered a 2nd inpatient hospital stay. 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 $370 
copayment each day for days 1 to 5 and $0 copayment for additional Medicare-covered days per admission for 
inpatient hospital services.  
 
 
  You have been asked to pay a total copayment of $1,850 for an IRF stay ($370 per day x 5 days = $1,850). 
This item/service falls within the inpatient 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 an IRF stay provided from July 1, 2022, to July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(G0453), provided on October 27, 2022. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that the 
service was medically necessary. The Plan denied your request. The Plan says this service is not covered for 
the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that G0453 is covered for specific diagnoses. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous intraoperative neurophysiology monitoring have not been met. Specifically, this service is not covered for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pay for 
the continuous intraoperative neurophysiology monitoring (G0453), provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 27, 2022, to October 1, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed 
income and cannot afford the cost sharing. 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 $375 
copayment for each day for days 1-5 of each inpatient hospital stay.  
 
You have been asked to pay a $375 copayment per day for days 1-4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,500 ($375 copayment per day x 4 days = $1,500). This item/service falls within 
the inpatient hospital 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 an inpatient 
hospital stay provided from September 27, 2022, to October 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 24, 
2022, to October 27, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not in the 
intensive care unit (ICU) during your stay. 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 $315 
copayment for days 1-6 for each inpatient hospital stay.  
 
You have been asked to pay a $315 copayment per day for days 1-3 of the inpatient hospital stay. You are 
being asked to pay a total of $945 ($315 copayment per day x 3 days = $945). These items/services fall within 
the inpatient hospital 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 an inpatient 
hospital stay from October 24, 2022, to October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid repair (V5014) provided on 
November 22, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract says that service costs for hearing aid 
maintenance are excluded from coverage. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aid repair (V5014) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of caries arresting medicament (D1354) Tooth 
#20 and 21 provided on October 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe these services listed may be indicating 
a cleaning, so you do not understand why it was not covered. The Plan denied your request. The Plan says this 
service is 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. Application of caries arresting 
medicament (D1354) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1354 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for application of 
caries arresting medicament (D1354) Tooth #20 and 21 provided on October 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 2, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you could not decide 
which ambulance company was used for this service. 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 $325 
copayment for each out-of-network one-way Medicare-covered ambulance trip.  
 
You have been asked to pay a $325 copayment for the ambulance service. This item/service falls within the 
ambulance 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 the ambulance 
services provided on November 2, 2022.