Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you do not feel that you should have to pay for 
this. 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 January 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 100 additional routine transportation trips. 
 
You asked the Plan to pre-approve 100 additional routine transportation trips. You say that you need 
transportation to visit your doctor twice a week. The Plan denied your request. The Plan says this request 
exceeds the maximum trips covered by your benefit. 
 
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 Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 100 additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM. 
 
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 therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor 
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on January 20, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. 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 were non-emergent and prior authorization was not obtained. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) with supplies and 
accessories (K05553, K0554). 
 
You asked the Plan to pre-approve a CGM with supplies and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 or 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 with supplies and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) with 
supplies and accessories (K05553, K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery on June 14, 2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you are requesting your 
copayment be reduced to $250. The Plan denied your request. The Plan says the cost sharing you are being 
charged is correct. 
 
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 $450 
copayment for outpatient procedures/surgery at an outpatient hospital. If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an outpatient. 
 
 
 You have been asked to pay a $450 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on August 30, 2021. 
 
You asked the Plan to pay for medical nutrition therapy.. You say that the patient has prediabetes and was 
trying to get this condition under control. The Plan denied your request. The Plan says this service is not 
covered because the patient does not have either renal disease or diabetes. The Plan must follow Medicare 
rules. Medicare rules say that medical nutrition therapy is coverable for patients with either a diagnosis of renal 
disease or diabetes.  The patient in this case does not have either renal disease or diabetes. Based on this 
information, we decided that Medicare rules for coverage of medical nutrition therapy. have not been met. 
Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on August 30, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit and be safest 
at a long-term acute care hospital. The Plan denied your request. The Plan says rules for SNF care have not 
been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee needs the repair. The Plan denied 
your request. The Plan says the service is available by a provider in the enrollee's network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
periapical x-ray (D0220), and a panoramic x-ray (D0330) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told the provider was out-of-
network. 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. 
 
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 a periodic oral evaluation (D0120), prophylaxis (D1110), periapical x-ray (D0220), and a panoramic 
x-ray (D0330) provided on June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would lack the ability to 
regain maximum function at a lower level of care. The enrollee would benefit and be safest at a long-term acute 
care hospital due to the medical complexity. The Plan denied your request. The Plan says rules for LTACH 
care have not been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on June 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for intraperitoneal procedures in upper abdomen 
including laparoscopy; not otherwise specified (00790) provided on December 10, 2020. 
 
You asked the Plan to pay for anesthesia. You say that you do not agree with the denial of this claim. You also 
say the original claim was submitted timely and was denied for no authorization, so a corrected claim was 
submitted. The Plan denied your request. The Plan says the claim was received by the Plan on 02/11/2022, 
which is outside of the 1 year allowed timeframe for a claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for anesthesia was not filed until February 11, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for anesthesia for intraperitoneal procedures in upper abdomen including 
laparoscopy; not otherwise specified (00790) provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's admission to an inpatient rehabilitation 
hospital is needed. The Plan denied your request. The Plan says that rules for IRF care have not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's current medical conditions are acute enough to require the intensity of rehabilitation 
physician oversight provided in the acute inpatient rehabilitation 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 a shower chair with accessories. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under the enrollee's 
contractual policy or 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. Additionally, the rules say that Medicare will pay for durable medical 
equipment that is mainly used to serve a medical purpose. 
 
 While a shower chair with accessories may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair with 
accessories.
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 you were independent before your hospitalization 
and want to return to being independent. You say that you are eager to participate in the 3 hours of aggressive 
rehabilitation that an IRF will offer. The Plan denied your request. The Plan says admission was denied as not 
meeting acute inpatient rehabilitation criteria, is not medically necessary, and a lower level of care might be 
appropriate. Skilled nursing facility level of care was offered. 
 
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 for anemia and gastrointestinal bleeding. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While you have 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90791) provided on March 30, 
2022, by a provider who is not enrolled in the Medicare program. 
 
You asked the Plan to pay for psychotherapy services. You say that you received a list of eligible providers. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled and is not eligible to 
enroll in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy 
services (90791) provided on March 30, 2022, by a provider who is not enrolled in the Medicare program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the request for Intracept intraosseous 
basivertebral nerve ablation at L4, L5, and S1 is not medically reasonable or necessary. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.