Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services (S5131). 
 
You asked the Plan to pre-approve the homemaker services. You say that you broke your wrist and you need 
someone who will take care of you. You also say you can't manage on your own and this service should be 
covered. The Plan denied your request. The Plan says homemaker services are not a covered benefit by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the homemaker services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
homemaker services (S5131).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you would like to see the OON provider. The 
Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
physical therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray, a CT scan, inpatient hospital stay, 
and outpatient services provided from July 11, 2022, to October 14, 2022. 
 
You asked the Plan to waive the copayment for an x-ray, a CT scan, an inpatient hospital stay, and outpatient 
services. You say that all of your claims have been denied and the facility is discontinuing treatment until 
everything is resolved by the Plan. 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 $295 
copayment per day for days 1 to 7 and $0 copayment for days 8 to 90 for an inpatient hospital stay, a $40 
copayment for Medicare-covered x-rays and a $250 copayment for Medicare-covered diagnostic radiology 
services, and a $295 copayment for all other outpatient services not provided in an ambulatory surgical center. 
 
You have been asked to pay $2,505.76 for an x-ray, a CT scan, inpatient hospital stay, and an outpatient 
services.  
 
Date of Service Service Rendered Allowed Amount per Contract Cost Share applied 
July 11, 2022 X-Ray (71046) $97.32 $40 copayment $40 
July 19, 2022 CT scan (71250) $105.76 $250 copayment $105.76 (which is less 
than the standard 
copayment) 
July 28, 2022, to 
August 7, 2022 
Inpatient Hospital 
Stay 
$29,438.86 $295 copayment per 
day for days 1 to 7 and 
$0 copayment for days 
8 to 90 
$2,065  
($295 per day x 7 days = 
$2,065) 
October 14, 
2022 
Outpatient Services $1,607.10 $295 copayment $295 
Total    $2,505.76 
 
The x-ray and CT scan fall within the outpatient diagnostic tests benefit category. The inpatient hospital stay 
falls within the inpatient hospital care benefit category. The outpatient services fall within the outpatient 
surgery 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 x-ray, a CT scan, 
inpatient hospital stay, and outpatient services provided from July 11, 2022, to October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injections and specialist visits provided from 
October 27, 2022, to December 30, 2022. 
 You asked the Plan to waive the cost share for injections and specialist visits. You say that all of your claims 
have been denied and the facility is discontinuing treatment until everything is resolved by the Plan. 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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs and a $25 copayment for 
each Medicare-covered specialist visit.  
 
You have been asked to pay 20% coinsurance for each Medicare Part B drug injection and $25 copayment for 
each specialist visits. The injections fall within the Medicare-covered Part B Prescription Drugs benefit 
category. The specialist visits fall within the Physician/Practitioner 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. Therefore, we decided that the Plan 
does not have to waive the cost share for injections and specialist visits provided from October 27, 2022, to 
December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that you tried the FreeStyle 2 and it 
made your skin breakdown from the patches. You also say that your doctor told you to try the FreeStyle 3 and 
you haven't had any problems since. The Plan denied your request. The Plan says you are requesting a CGM 
product that does not meet Medicare's definition of durable medical equipment (DME) and, therefore, is not in 
a defined Medicare benefit category. 
 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 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided 
from February 27, 2023, through March 8, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an out-of-network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.   
 
 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatments (98941) provided from February 27, 
2023, through March 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that you do not have enough pain medication to last a full 
month. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the records shows that you have neck pain 
but no radicular symptoms or red flags. No conservative therapy including PT has been done. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment (E0486). 
 
You asked the Plan to pre-approve an oral device. You say that the requested device is urgently needed and 
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for approval of 
the requested oral device. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 an oral device. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have obstructive sleep apnea, established with polysomnography on September 7, 
2018. The overall AHI was 47. You are intolerant of a continuous positive airway pressure (CPAP) device. 
You have had a mandibular advancement device previously which has worn out. You have had a recent in 
person medical evaluation and the order has been written by a dentist. A mandibular advancement device is 
reasonable and medically necessary. The denial is reversed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral device have been met. Therefore, we decided that the Plan has to pre-
approve an oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, 
custom fabricated, includes fitting and adjustment (E0486).   
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 filling (D2330) provided on February 9, 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 a filling 
(D2330) provided on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Mobility zero turn scooter. 
 
You asked the Plan to pre-approve a Pride Mobility scooter. You say that the requested scooter is medically 
necessary. The Plan denied your request. The Plan says only the preferred brand products listed 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. The record shows the requested brand is not a preferred brand for 
power operated and motorized vehicles. Therefore, we decided that the Plan does not have to pre-approve a 
Pride Mobility zero turn scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and biopsy of skin provided on February 2, 
2023. 
 
You asked the Plan to pay for office visit and biopsy. You say that your dentist discovered a lesion in your 
mouth they believed to be cancerous. Other providers could not perform the biopsy for several weeks. The Plan 
denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit and biopsy of skin provided on February 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on February 17, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 physical therapy 
provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6059), abutment supported porcelain fused to metal crown (D6060) and implant placement (D6010). 
 
You asked the Plan to pre-approve implants and associated services. 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 pre-approve 
abutment supported porcelain fused to metal crown (D6059), abutment supported porcelain fused to metal 
crown (D6060) and implant placement (D6010).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on March 01, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were 
advised there were no copayments for MRI 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 $300 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $300 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $235.10, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection provided on January 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the injection. You say that the injection proved to be beneficial to the enrollee. 
The Plan denied your request. The Plan says the injection can be 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 the injection provided on January 4, 2023, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy provided on September 01, 2022. 
 
You asked the Plan to pay for home infusion therapy. You say that you are appealing the claim payment denial. 
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 home infusion therapy 
provided on September 01, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0157, G0151, 
G0152, G0157, Q5001) provided on March 9, 2022, to April 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 9, 2022. The NOA was not received by the Plan until May 19, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, G0152, 
G0157, G0151, G0152, G0157, Q5001) provided on March 9, 2022, to April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 10, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on January 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 1, 2022, to May 31, 
2022, by an OON provider.  
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility care provided on May 1, 2022, to 
May 31, 2022, by an OON provider.