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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this sensor is medically 
necessary. The Plan denied your request. The Plan says the enrollee is not on insulin. 
 
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 a continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's needs can be met in an alternate level of care. 
 
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 documentation does not support the medical necessity for admission to an 
IRF. The enrollee has no acute medical complexity and no acute rehabilitation nursing needs for an IRF 
admission. While the enrollee would benefit from physical therapy and occupational therapy, the enrollees rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on September 27, 2022. 
 
You asked the Plan to pay for pain management. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pain management 
provided on September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for colonoscopy provided on September 29, 
2022. 
 
You asked the Plan to waive the deductible for colonoscopy. You say that you should not have to pay for the 
colonoscopy because it was a preventive procedure. 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 $750 
deductible for What is your plan deductible?. 
 
You have been asked to pay a $750 deductible for colonoscopy. This item/service falls within the What is your 
plan deductible? 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 deductible for colonoscopy 
provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam provided on September 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the provider performing the service in the 
nursing home facility is not responsible to obtain authorization. The Plan denied your request. The Plan says 
the service was not authorized. 
 
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 did not pre-approve the 
medical eye exam. We found no exception that would require the Plan to pay for the medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam provided on September 15, 
2022, by an out-of-network (OON) provider.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the documentation does not support that the enrollee has a need for complex 
medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital or the skilled nursing facility. The enrollee has improved medically and can 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a dental cleaning (D1110) provided on October 25, 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 that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a dental cleaning (D1110) provided on October 
25, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on September 14, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you wouldnt have taken the 
abmulance if you knew there was a 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 $250 
copayment for ambulance service. 
 
You have been asked to pay a $250 copayment for ambulance. This item/service falls within the ambulance 
service 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 ambulance provided on 
September 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
September 27, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you just went for an 
office visit. 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 $120 
copayment for outpatient hospital services/tier 1.  
 
You have been asked to pay a $120 copayment for an outpatient hospital visit. This item/service falls within the 
outpatient hospital services/tier 1 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 outpatient hospital visit provided on September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal injection (code 62323) provided on 
June 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you were never told 
there would be a copayment and you have never had such a big copayment on any services. 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 $250 
copayment for each in-network Medicare-covered outpatient hospital service, including outpatient surgery or 
procedures 
 
You have been asked to pay a $250 copayment for each in-network Medicare-covered outpatient hospital 
service, including outpatient surgery or procedures. This item/service falls within the outpatient 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. According to Medicare, a spinal injection (code 62323) is considered a surgical procedure. Therefore, we 
decided that the Plan does not have to waive the copayment for a spinal injection (code 62323) provided on 
June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4034 and B4035 billed for date of service 
June 17, 2022. 
 
You asked the Plan to pay for procedure codes B4034 and B4035. The Plan denied your request. The Plan says 
the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for codes B4034 and B4035 is 1. The MAI value for this code is 1. You billed 4 units of 
code B4034 and 30 units of code B4035 on the same claim lines, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure codes B4034 and B4035 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes B4034 and B4035 billed for 
date of service June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation established patient (D0120) and 
prophylaxis - adult (D1110) provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why your oral evaluation 
and cleaning was not paid for. 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. This benefit includes the 
requested periodic oral evaluation established patient and prophylaxis  adult but there is a combined $1,000 
coverage limit each plan year for Preventive and Comprehensive dental services. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit limit of $1,000 coverage limit was exhausted on date of service June 8, 2022. Therefore, we 
decided that the Plan does not have to pay for periodic oral evaluation established patient (D0120) and 
prophylaxis - adult (D1110) provided on October 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services could have been provided 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 psychotherapy provided on September 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on March 16, 2022. 
 
You asked the Plan to pay for a specialist office visit. You say that although no referral was obtained, you 
believe the services rendered were medically necessary. 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 specialist office visit 
provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (A4595) provided on July 20, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (A4595) provided on July 20, 
2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department services (procedure code 99284) provided to the 
enrollee on October 11, 2021. 
 
You asked the Plan to pay for the services. You say that the patient was seen twice on the same date of service 
at two different times and/or by two different providers. The Plan denied your request. The Plan says that the 
claim was already processed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99284 is "Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the 
physician, or other qualified health care professionals but do not pose an immediate significant threat to life or 
physiologic function." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the patient was seen at two separate 
times on October 11, 2021. The first record shows that the patient presented around 4 am on the date in 
question, and was treated and discharged home. The second visit occurred around 7 pm on the same date of 
service and the same complaint was addressed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
emergency department services (procedure code 99284) provided to the enrollee on October 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are unable to afford the cost 
share for services rendered. 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 service. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the 
physician/practitioner service 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 May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown repair services (D2980) provided on August 31, 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 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 pay for crown 
repair services (D2980) provided on August 31, 2022.