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

 
We decided that the Plan does not have to pay for the Peloton fitness classes purchased on January 1, 2022. 
 
You asked the Plan to pay for the Peloton fitness classes. You say that you believe the Peloton fitness classes 
fall under the fitness center benefit and should be covered. The Plan denied your request. The Plan says Peloton 
is not a covered reimbursement benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers Fitness 
Center/Weight Watchers/Acupuncture/Activity Tracker services. 
 
The Plans rules for coverage of these benefits have not been met because Peloton is not a listed benefit. 
Therefore, we decided that the Plan does not have to pay for the Peloton fitness classes purchased on January 1, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient hospital services provided on May 31, 2022, billed 
with procedure code 99221-25-GC. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the services were billed with the incorrect place of 
service code. 
 The Plan must follow Medicare rules. Medicare rules say that the POS code is generally used to reflect the 
actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have been met. It is not appropriate to report inpatient evaluation 
and management service and place of service 21 when the patient's claim history shows that the patient was in 
an outpatient hospital observation status for this date of service. Therefore, we decided that the Plan does not 
have to pay for Inpatient hospital services provided on May 31, 2022, billed with procedure code 99221-25-
GC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and crown lengthening (D4249) for 
tooth #4, and the repair of maxillofacial soft tissue (D7955). 
 
You asked the Plan to pre-approve the dental services. You say that the crown is actively causing periodontal 
issues. The Plan denied your request. The Plan says the denial of the crown and crown lengthening is correct 
because the x-rays do not show a cavity under the old cap. Also, the repair of maxillofacial soft tissue is not 
covered by the 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. 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 the replacement crown and crown lengthening for tooth #4 does not meet the criteria for coverage. Our 
physician reviewer found that the documentation indicates that due to the short root of tooth #4, a crown 
lengthening procedure would create a poor crown root ratio, therefore a poor prognosis for long term tooth 
retention. 
 
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 for the crown and crown lengthening for 
tooth #4. The repair of maxillofacial soft tissue is not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pre-approve a crown (D2740), and crown lengthening (D4249) for tooth 
#4, and the repair of maxillofacial soft tissue (D7955).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the periodic comprehensive preventive medicine reevaluation provided 
on December 13, 2022. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation. You say that this 
exam was medically necessary for a new primary care visit. The Plan denied your request. The Plan says that 
the claim is denied. 
 
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 has not provided a Medicare rule, a Plan rule or a reason to 
substantiate their denial. Therefore, we decided that the Plan has to pay for the periodic comprehensive 
preventive medicine reevaluation provided on December 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have a qualifying chronic condition that 
you are eligible to receive the allowance for. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
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 pre-approve Ozempic.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says additional days may be covered when the enrollee has been out of a hospital 
or facility primarily providing skilled nursing or rehabilitation services for 60 days in a row. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from September 7, 
2022, through May 7, 2023. The Plan has covered 100 days of SNF care.  
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs the requested foot orthotics 
because they have issues with their hands. 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 foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth number 6. 
 
You asked the Plan to pre-approve the dental services. You say that your crown needs to be replaced because it 
is loose. The Plan denied your request. The Plan says the request to replace the crown is not medically 
necessary at this time. 
 
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. The Plans criteria for coverage for a 
replacement crown say there needs to be evidence of decay or a missing crown to support the need for a 
replacement. 
 
 
  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 the request for a replacement crown does not meet the criteria for coverage. Our physician reviewer found 
that the documentation indicates that the crown in place on tooth number 6 is loose. There was no indication 
whether the crown could be recemented. The x-rays were not of diagnostic quality therefore, no determination 
of recurrent caries or fracture could be made. 
 
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 crown for tooth number 6.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance arrived, cooled you down and you felt better. You also say that you did not need hospitalization and 
as a result you feel you should not be charged for the service. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that your Utility Flex Card did not work when you 
used it to pay for your light bill. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0270) provided on November 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist because you had pain in 
your tooth, and you would like the doctor to be paid. 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 the date of service of September 22, 
2022. Therefore, we decided that the Plan does not have to pay for the bitewings (D0270) provided on 
November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
January 11, 2023. 
 
You asked the Plan to pay more for the dental service. You say that dental extraction received was necessary 
and believes the plans allowance should be greater. You also say that you should not be held liable for the 
remaining balance. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) 
provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic film (D0330) provided on February 2, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new provider, and you did not 
know you were not eligible to have an x-ray done. 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 the date of service of August 16, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic film (D0330) provided on February 
2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve Contour Next test strips. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve Contour 
Next test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with code 81479 for date of 
service December 20, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing billed 
with code 81479 for date of service December 20, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 3, 2021, 
through October 5, 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 that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the review indicates that the enrollee presented to the emergency department (ED) on October 3, 
2021 via ambulance with chest pain with associated nausea and vomiting. On evaluation she was 
hemodynamically stable; the exam revealed an irregular heart rate. The electrocardiogram initially showed 
atrial fibrillation which converted to a normal sinus rhythm without any acute ischemic changes. The chest  
x-ray was normal and the computed tomography (CT) scan of the chest was negative for a pulmonary 
embolism. The laboratory services revealed normal liver function and normal troponin. She was admitted to 
observation. She was evaluated for a gall bladder source of pain with an abdominal ultrasound which revealed 
gall bladder thickening but no stones. She was evaluated by Cardiology on October 4, 2021 and was felt to 
have atypical chest pain. She was evaluated by General Surgery and a nuclear medicine hepatobiliary scan was 
negative for a cystic duct obstruction. She refused a laparoscopic cholecystectomy and was discharged home 
with outpatient follow-up on October 5, 2021. The review indicates that the record showed that at the time of 
the inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 3, 2021, through October 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you need a CGM. 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 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 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).