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

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 continuous glucose monitor (CGM), 
supplies and accessories. 
 
You asked the Plan to pre-approve the CGM supplies and accessories.. You say that the medical records to 
support this appeal. The Plan denied your request. The Plan says you do not meet the requirements for 
approval. 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 continuous glucose monitor (CGM), supplies and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 10, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 
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 physician's services provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 20, 2023, 
February 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for inpatient hospital services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 inpatient hospital services provided on February 
20, 2023, February 22, 2023, by an out-of-network (OON) provider.
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 you are requesting reconsideration for the denial of 
a SNF admission so you can get stronger and feel safer at home. The Plan denied your request. The Plan says 
you do not meet the Medicare criteria for admission to a SNF.  
 
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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network eye procedures provided on 
April 19, 2023, and on April 26, 2023. 
 
You asked the Plan to waive the copayment for in-network eye procedures. You say that these procedures were 
to correct and issue that happened during the previous surgeries. You should not have to pay again. 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 $290 
copayment for Medicare-covered ambulatory surgical center visits.  
 
You have been asked to pay the allowed total amount of $521.34 which is less than the $580 total copayment 
for in-network eye procedures ($260.67 per procedure x 2 = $521.34).  This item/service falls within the Medicare-covered ambulatory surgical center visits 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 in-network eye procedures provided on April 19, 2023, and 
on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images  
(D0210), and topical application of fluoride  excluding varnish (D1208) provided on April 18, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images, and topical 
application of fluoride  excluding varnish. You say that the providers office stated that you owed nothing for 
the services that day. The Plan denied your request. The Plan says these services are not covered your dental 
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. 
 
 
 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 an 
intraoral  comprehensive series of radiographic images  (D0210), and topical application of fluoride  
excluding varnish (D1208) provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses (V2200) and frames (V2020) provided from 
January 4, 2023, to January 11, 2023.  
You asked the Plan to pay for bifocal lenses (V2200) and frames (V2020). You say that you received a 
payment of $100 after submitting the invoices. The Plan denied your request. The Plan says this benefit is 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $100 allowance is towards the purchase of any other frame/lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that a $100 allowance is available towards the 
purchase of any other frame/lenses. Based on this information, we decided that the Plan's rules for coverage of 
bifocal lenses (V2200) and frames (V2020) have not been met. Therefore, we decided that the Plan does not 
have to pay for bifocal lenses (V2200) and frames (V2020) provided from January 4, 2023, to January 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown for tooth #3 and #14 (D2740) provided on 
March 2, 2023, to March 20, 2023. 
 
You asked the Plan to pay more 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 cost-sharing applied correctly based 
on the services provided. 
 
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 a 50% coinsurance for a crown for teeth #3 and #14. This item/service falls within 
the class 3 major 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance procedures (D6080) provided on April 
11, 2023. 
 
You asked the Plan to pay for implant maintenance procedures. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 implant 
maintenance procedures (D6080) provided on April 11, 2023.
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 February 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that that the 
ambulance was called by the staff at the facility you were at. You also say that you were fine to drive yourself 
to the hospital. 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 February 27, 2023. 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 February 27, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Avastin (Bevacizumab) provided on August 24, 2022. 
 
You asked the Plan to pay for Avastin (Bevacizumab). You say that you are requesting the claim be reviewed 
and approved. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Avastin (Bevacizumab). Our reviewer says 
that the requested treatment, Avastin, meets the criteria for approval. Our physician reviewer found Avastin is 
FDA-approved for the treatment of metastatic colorectal cancer as the first- or second-line therapy, in 
combination with IV 5-fluorouracil based chemotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin (Bevacizumab) have been met. Therefore, we decided that the Plan has 
to pay for Avastin (Bevacizumab) provided on August 24, 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 pay for a handheld magnifier (V2600) provided on February 14, 
2023. 
 
You asked the Plan to pay for a handheld magnifier (V2600). You say that you have macular degeneration, and 
you need the aid to assist in reading. You also say you feel that this item should be covered by the Plan. The 
Plan denied your request. The Plan says low vision aids are not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision examinations and standard eyewear. Low vision aids not excluded 
from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers routine vision examinations 
and one pair of standard eyeglass frames and standard plastic eyeglasses lenses per calendar year. A handheld 
magnifier (V2600) is excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of a handheld magnifier (V2600). have not been met. Therefore, we decided that the Plan does not 
have to pay for a handheld magnifier (V2600) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (excluding final 
restoration) (D3310), and core buildup, including any pins when required (D2950) provided on April 27, 2023. 
 
You asked the Plan to pay for the endodontic therapy, anterior tooth and core buildup. The Plan denied your 
request. The Plan says these services are not covered. 
 
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 endodontic therapy, anterior tooth 
and core buildup are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for endodontic therapy, anterior tooth (excluding final restoration) (D3310), and core buildup, 
including any pins when required (D2950) provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor and supplies. 
 
You asked the Plan to pre-approve Freestyle Libre 2 Sensor and supplies. You say that  it is medically 
necessary for you to receive the Freestyle Libre 2 Sensor and supplies because you do not like pricking your 
finger. The Plan denied your request. The Plan says you do not meet the criteria for a therapeutic CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 Freestyle Libre 2 Sensor and supplies. 
Our reviewer says that you do not meet Medicare criteria. Our physician reviewer found you are not on 
medication which cause low blood sugars and you are not taking insulin. Your control of a1c seems excellent 
and is at goal. Therefore, you are not at risk of low blood sugar. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre 2 Sensor and supplies have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Freestyle Libre 2 Sensor and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient L1 kyphoplasty (22514).  
 
You asked the Plan to pre-approve kyphoplasty. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says fracture retropulsion/canal compromise is a relative contraindication for this 
procedure 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered when the criteria in the rules 
section of this letter are met. 
 
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 kyphoplasty. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, greater than 25% 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion and other plausible causes of pain in the 
lumbar spine. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the outpatient L1 kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the exercise classes (S9451) provided from 
January 5, 2022, through December 5, 2022. 
 
You asked the Plan to issue reimbursement 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 at 
issue are not payable as they were rendered by an out-of-network provider.  
 
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 exercise classes provided in this 
case were rendered by an out-of-network provider. The fitness benefit includes coverage for fitness classes 
only when provided by the Plans select fitness vendor. Therefore, we decided that the Plan does not have to 
issue reimbursement for the exercise classes (S9451) provided from January 5, 2022, through December 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on March 8, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says telehealth services are not covered out-of-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 Plan contract also says that virtual care (also referred to as 
telehealth services, virtual check-ins or eVisits) are not covered out-of-network. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. The Plan does not cover telehealth out-of-network. 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 telehealth 
services provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated abutment (D6056) and implant supported 
crown (D6066). 
 
You asked the Plan to pay for prefabricated abutment and implant supported crown. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
prefabricated abutment (D6056) and implant supported crown (D6066).