Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on January 13, 2022, 
through January 14, 2022. 
 
You asked the Plan to pay for the medication. You say that the services were medically necessary. 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 pay for the self-administered drugs 
received on January 13, 2022, through January 14, 2022.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 8, 2023, to May 
9, 2023. 
 
You asked the Plan to pay for the medication. You say that you were given the meds during your stay at the 
emergency room. 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 pay for self-administered drugs provided 
from May 8, 2023, to May 9, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on March 25, 
2023. 
 You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room (ER) services provided on March 25, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor (95249). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. 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 CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM) sensor (95249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials, guided tissue regeneration, and bone 
replacement graft (D3431, D4266, D7953) provided on March 22, 2023. 
 
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 biologic 
materials, guided tissue regeneration, and bone replacement graft (D3431, D4266, D7953) provided on March 
22, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 19, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the transport was not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on May 4, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were under full anesthesia for the 
procedure performed and did not administer any drugs yourself. 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 pay for the self-administered drugs 
received on May 4, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) scans of the middle 
and lower spinal canal provided on February 14, 2023. You asked the Plan to pay for the MRI scans. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 13, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) scans of the middle and lower spinal canal provided on February 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee does not have a smoking history of at 
least 20 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 8, 2022, to April 
18, 2022. 
 You asked the Plan to pay for the home health services. You say that the enrollee was not on hospice during 
this period. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services provided from April 8, 2022, to April 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership purchased on 
February 16, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
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 Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit.  
  
 
 
Specifically, the Plans contract states that coverage is provided for a fitness membership through the Plans 
select fitness provider. However, in this case, you purchased a health club membership from an out-of-network 
provider. Additionally, the Plans contract states that enrollees receive $300 every three months on a Flex card 
that may be utilized for qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. 
Therefore, we decided that the Plan does not have to issue reimbursement for the health club membership 
purchased on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic radiographic image (D0330) provided on May 3, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for the dental service provided in this case.  
 
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 Plans contract states that a panoramic radiographic image is 
covered once every 60 months. The Plan has stated that you have exhausted the allowable benefit for this 
dental service provided in this case. However, the Plan has not provided substantiative evidence that indicates 
this service was previously provided and paid for by the Plan. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the panoramic 
radiographic image (D0330) provided on May 3, 2023.  
 
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 pay for the resin-based composite-one surface, anterior (D2330) and 
the resin-based composite-one surface, posterior (D2391) provided on May 15, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the dental items provided in this case are not covered 
under the supplemental dental policy.  
 
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 dental items provided are not 
among those covered under this benefit.   
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the resin-based composite-one surface, anterior 
(D2330) and the resin-based composite-one surface, posterior (D2391) provided on May 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 4, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was used to try to stop a nosebleed 
in the emergency room. 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 pay for self-administered drugs provided 
on May 4, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight test provided on March 18, 2023. 
 
You asked the Plan to pay for the GeneSight test. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this claim was billed with a GY modifier indicating this test 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 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 GeneSight test have been met. The 
record does not include a copy of the claim or documentation showing the GY modifier was used. Therefore, 
we decided that the Plan does not have to pay for the GeneSight test provided on March 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership purchased on 
February 16, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
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 Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider. However, in this case, you purchased a health club 
membership from an out-of-network provider.   
 
 
 
Additionally, the Plans contract states that enrollees receive $300 every three months on a Flex card that may 
be utilized for qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. Therefore, we 
decided that the Plan does not have to issue reimbursement for the health club membership purchased on 
February 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 11, 
2022, to June 1, 2022. 
 You asked the Plan to pay for SNF care. You say that SNF stay should be fully covered. The Plan denied your 
request. The Plan says the enrollee's needs could have been provided at a lower level of care.  
 
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 the enrollee doesn't have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs; 
however, the enrollee doesnt 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 have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 11, 2022, to June 1, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (PT) services provided on March 2, 2023. 
 
You asked the Plan to pay for the therapy services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that the provider must bill the enrollee's primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for physical therapy (PT) services provided on March 2, 2023.  
 
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 pay for a partial mandibular denture (D5214) provided on May 2, 
2023. 
 
You asked the Plan to pay for the dental services. You say that dentures are covered. The Plan denied your 
request. The Plan says your dental annual maximum amount has 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 annual dental allowance amount was exhausted on date of service May 2, 2023. Therefore, we 
decided that the Plan does not have to pay for the remaining amount of $167 for a partial mandibular denture 
(D5214) provided on May 2, 2023.