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

 
We decided that the Plan does not have to pre-approve Contour test strips. You asked the Plan to pre-approve the test strips. You say that the enrollee already has a Contour glucose meter 
and needs the test strips. The Plan denied your request. The Plan says that only Abbott and Lifescan products 
are covered. 
 
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. According to the EOC, Contour is not a preferred brand for diabetic 
supplies. Therefore, we decided that the Plan does not have to pre-approve Contour test strips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 17, 2023. 
 
You asked the Plan to pre-approve SNF care after March 17, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after March 17, 2023. 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 after March 17, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212), and maxillary 
partial denture (D5213). 
 
You asked the Plan to pre-approve codes D5212 and D5213. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 pre-approve a 
mandibular partial denture (D5212), and maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the toilet rail. 
 
You asked the Plan to pre-approve toilet rail. You say that you would like reconsideration because the 
requested toilet rail is medically necessary. The Plan denied your request. The Plan says the requested toilet rail 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve the toilet rail.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940, 98941), 
office visits (99202, 99211), manual therapy (97140), therapeutic exercises (97110), and the ultrasound therapy 
(97035) provided from January 25, 2022, through October 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
The records show that the services at issue are not covered by the Plan or by Medicare. Additionally, the 
chiropractic manipulative treatments provided in this case are considered maintenance therapy as billed, which 
is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatments (98940, 98941), office visits (99202, 99211), manual therapy (97140), therapeutic 
exercises (97110), and the ultrasound therapy (97035) provided from January 25, 2022, through October 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), manual therapy (97140), chiropractic 
manipulative treatment (98940), and the x-ray exam of the spine (72020) rendered by the out-of-network 
(OON) provider from June 15, 2021, through December 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99202), manual therapy (97140), chiropractic manipulative 
treatment (98940), and the x-ray exam of the spine (72020) rendered by the out-of-network (OON) provider 
from June 15, 2021, through December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, we decided that the Plan has to pre-approve the 
SSBCI benefits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular partial denture (D5213, 
D5214). 
 
You asked the Plan to pre-approve the dental services.. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary and mandibular partial denture (D5213, D5214).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance imaging (MRI) of the face provided by an out-of-
network provider on June 10, 2022. 
 
You asked the Plan to pay for the MRI. You say that the service provided to the enrollee was medically 
necessary. The Plan denied your request. The Plan says that the rendering provider was an OON provider and 
there was no approved authorization on file. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover medically necessary services 
received from non-contracted providers without prior authorization when an enrollee is on a PPO Plan.  
 
We looked at the file and Medicare rules. The Plan has not substantiated their denial reason of prior 
authorization being required because the provider was OON. The enrollee is on a PPO Plan and there cannot be 
prior authorization requirements for non-contracted providers. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pay for a 
magnetic resonance imaging (MRI) of the face provided by an out-of-network provider on June 10, 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 pay for a Freestyle Libre 3. 
 
You asked the Plan to pay for a Freestyle Libre 3. You say that this is medically necessary. The Plan denied 
your request. The Plan says a Freestyle Libre 3 is not a covered benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does not have to pay for 
a Freestyle Libre 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, panoramic x-ray, tooth extraction, 
and a skin graft (D0140, D0330, D7140, D7920) provided on September 6, 2022, to October 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the 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 limited oral evaluation, panoramic x-ray, tooth extraction, and a skin graft (D0140, D0330, D7140, 
D7920) provided on September 6, 2022, to October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter (K0800). 
 
You asked the Plan to pre-approve the motorized scooter. You say that the requested scooter is medically 
necessary. The Plan denied your request. The Plan says that a face-to-face evaluation was not completed for the 
requested scooter. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that a face-to-face evaluation was not completed to verify the enrollee's need and ability to use 
the requested motorized scooter. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a motorized scooter (K0800).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for outpatient mental health services. 
 
You asked the Plan to provide coverage for outpatient mental health services. You say that it would be a 
disruptive event, in a 3-year therapeutic relationship, to discontinue this relationship now. The Plan denied your 
request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to provide coverage 
for outpatient mental health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6242) and retainers (D6545) for tooth #21, 
#22, #23, #24, #25, #26, #27, and #28 to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the required documentation was not submitted to support 
the need for treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the dental services have been met. The 
x-rays provided with the supporting documentation are too dark to read and the records support multiple 
attempts were made to obtain readable x-rays to support the medical necessity of the requested dental 
treatment. Therefore, we decided that the Plan does not have to pre-approve pontics (D6242) and retainers 
(D6545) for tooth #21, #22, #23, #24, #25, #26, #27, and #28 to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and foot inserts. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. 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 diabetic shoes and foot inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a freestyle libre 3 sensors. 
 
You asked the Plan to pay for the freestyle libre 3 sensor. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
they are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the freestyle libre 3 sensor have not been met. Specifically, the requested CGM device does not 
meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for a freestyle libre 3 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. The Plan denied your request. The Plan 
says the conditions needed to approve this drug have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Freestyle Libre 14-day sensor have 
been met. Specifically, the records show that the Plan made multiple attempts to obtain additional information, 
but it was not received. Without the requested records, there is no evidence that the enrollee is using insulin 
with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan.. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network outpatient surgery provided 
on January 13, 2022. 
 
You asked the Plan to waive the coinsurance for a surgery service. You say that the provider was unable to 
complete the surgery. 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 10% 
coinsurance for outpatient surgery services provided at an outpatient facility. The record shows the claim was 
approved and you are responsible for a cost share amount, even though the procedure was not fully completed. 
 
You have been asked to pay a $215.32 coinsurance for a surgery service ($2,153.19 allowed amount x 10% 
coinsurance = $215.32 coinsurance). This item/service falls within the outpatient surgery services provided at 
an outpatient facility 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 an in-network 
outpatient surgery provided on January 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home aide services. 
 
You asked the Plan to pre-approve the aide services. You say that you need help. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the aide services have not been met. Therefore, we decided that the Plan does not have to pre-
approve home aide services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 15, 2022, to October 14, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer required 
daily skilled nursing facility needs. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from September 15, 2022, to October 14, 2022.