Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another 3-4 
weeks of care for transitioning from acute illness. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to be improving and should only require short-term 
additional acute care services that can safely be provided at the current facility until more appropriate and 
stable for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs can be met at the 
LTACH level of care. The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on January 10, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 a mental health visit provided on January 10, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for right knee pain. 
 
You asked the Plan to pre-approve a genicular nerve block for right knee pain. You say that a genicular nerve 
block for right knee pain is medically necessary. The Plan denied your request. The Plan says a review of the 
current medical literature does not consider this service to be standard medical treatment for this condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a genicular nerve block for right knee 
pain. Our reviewer says that the requested genicular nerve block for right knee pain is not considered medically 
reasonable and necessary. Our physician reviewer found genicular nerve block for right knee pain is considered 
an experimental/investigational procedure. The procedure is the subject of ongoing clinical trials. Therefore, 
the request is deemed not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block for right knee pain have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve block for right knee pain.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the colonoscopy, drug injections, and office 
visits provided from November 4, 2022, to December 29, 2022. 
 
You asked the Plan to reduce the cost share for the colonoscopy, drug injections, and office visits. You say that 
there are errors with these claims. 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 $350 
copayment for outpatient surgery provided at an outpatient hospital. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly 
says that you must pay a $40 copayment for each specialist office visit. 
 
Date of Service CPT Code Allowed Amount Copayment Coinsurance 
November 4, 2022 45380 $1,395.57 $350 - 
November 4, 2022 J2704 $2.02 - $0.40 
November 4, 2022 J3490 $0.14 - $0.3 
November 15, 2022 99205 $232.05 $40 - 
December 29, 2022 99213 $88 $40 - 
Total $430.43 
 
You have been asked to pay a $350 copayment for the colonoscopy procedure. This item/service falls within 
the outpatient surgery benefit category. You have also been asked to pay 20% coinsurance for each drug 
injection. This item/service falls within the Medicare Part B drugs bene category. You have also been asked to 
pay a $40 copayment for each specialist office visit. This item/service falls 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 reduce the cost share for the colonoscopy, drug 
injections, and office visits provided from November 4, 2022, to December 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 21, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 home health services have been 
met. No OASIS records were provided to support the billed skilled services.  Therefore, we decided that the 
Plan does not have to pay for home health services provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained intra-orally 
or extra-orally (D0350 x3), and oral hygiene instructions (D1330) provided on March 30, 2023. 
 
You asked the Plan to pay for the oral/facial photographic images and oral hygiene instructions. You say that 
you are asking for the denial to be reviewed and reversed. The Plan denied your request. The Plan says your 
benefit for the oral/facial photographic images has already been exhausted. The Plan also says that the oral 
hygiene instructions is not covered under the benefit package. 
 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 oral/facial photographic images was exhausted on date of service March 30, 2023. 
Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained 
intra-orally or extra-orally (D0350 x3) provided on March 30, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instructions are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture - cast metal framework with resin 
denture bases (D5213), and mandibular partial denture - cast metal framework with resin denture bases 
(D5214) provided on May 4, 2023. 
 
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that both or your partials 
do not fit anymore. You also say that you have two teeth that need to be extracted, one on top, and one on the 
bottom that are anchor teeth The Plan denied your request. The Plan says your benefit for the maxillary and 
mandibular partial dentures 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 maxillary and mandibular partial dentures was exhausted on date of service April 
10, 2019. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture - cast metal 
framework with resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin 
denture bases (D5214) provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided on May 22, 2023. 
 
You asked the Plan to pay for dental services. You say that you should not have to wait until you need a root 
canal in order to have a crown. The Plan denied your request. The Plan says these services are not covered 
under your 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. Core buildup, including any 
pins when required (D2950) is not covered under the Plans dental benefits. Crown - porcelain/ceramic 
(D2740) is limited to one crown per 12 consecutive months (combined with D2710, D2740, D2750, D2751, 
D2752, D2790, D2791, D2792, D2794) only in conjunction with a listed root canal procedure code. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit and D2740 is not covered because it is not in conjunction with a listed root 
canal procedure code. Therefore, we decided that the Plan does not have to pay for crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D6740) for teeth 11 and 13 
and a porcelain/ceramic pontic (D6245) for tooth number 12. 
 
You asked the Plan to pre-approve porcelain/ceramic crowns (D6740) for teeth 11 and 13 and a 
porcelain/ceramic (D6245) for tooth number 12. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that removable prosthodontics and other services that are not 
specifically identified as covered and are not covered under the 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 pre-approve 
porcelain/ceramic crowns (D6740) for teeth 11 and 13 and a porcelain/ceramic pontic (D6245) for tooth 
number 12.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 2, 2023. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says that  
in order for the facility to receive reimbursement for a Medicare member, the facility must be enrolled to 
participate in the Medicare program per CMS. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestylie Libre 3 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 Freestylie Libre 3 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9222 and D9223 x2) 
provided on December 16, 2022. 
 
You asked the Plan to pay for deep sedation/general anesthesia. 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 deep 
sedation/general anesthesia (D9222 and D9223 x2) provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown- porcelain/ceramic (D2740), core buildup (D2950), 
pontic (D6245) and retainer crown (D6740) provided on March 24, 2023. 
 
You asked the Plan to pay for these dental 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 pay for crown- 
porcelain/ceramic (D2740), core buildup (D2950), pontic (D6245) and retainer crown (D6740) provided on 
March 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided from 
January 30, 2023, to March 13, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that the Plan representative 
advised to change the enrollee's previous plan to save money but instead caused more financial burden due to 
the increased maximum out-of-pocket. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for chemotherapy drugs.  
 
The enrollee has been asked to pay $7,009.30 coinsurance for chemotherapy treatment ($35,046.55 allowed x 
20% = $7,009.30). This item/service falls within the Medicare Part B prescription drugs benefit category. 
When a new Plan is established, the maximum out-of-pocket (MOOP) starts over and any prior out-of-pocket 
expenses cannot be applied to the new MOOP. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
chemotherapy treatment provided from January 30, 2023, to March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.  
You asked the Plan to pre-approve the Freestyle Libre 14 day sensor. You say that you have used this for over 
a year. You also say that it helps with your blood pressure and keeps your blood sugar regularly down. The 
Plan denied your request. The Plan says the information available does not support that you have met this 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 14 day sensor.