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

 
We decided that the Plan does not have to pre-approve a freestyle lite test strip 
 
You asked the Plan to pre-approve the freestyle lite test strip. You say that the items should be covered as you 
disagree 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 freestyle lite test strip. Therefore, we decided that the Plan does not have to pre-approve a freestyle lite 
test strip
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 provided by an OON provider. You say that the enrollee 
would benefit from physical therapy visits. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that you would like the Plan to approve the 
dental service. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of July 2, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic retainer crowns (D6740 x 2) and 
porcelain/ceramic pontics (D6245 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under 
your 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 requested dental items are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
porcelain/ceramic retainer crowns (D6740 x 2) and porcelain/ceramic pontics (D6245 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional routine transportation miles. You say that you are requesting 
assistance to extend your benefits over the 50 mile limit to see a doctor. The Plan denied your request. The Plan 
says your request is beyond the coverage limit. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You are requesting trips that exceed the 
50-mile limit. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor.  
You asked the Plan to pre-approve the FreeStyle Libre Kit 2 sensor. You say that the enrollee has been placed 
on Ozempic and with a need to be monitored more closely. The Plan denied your request. The Plan says the 
enrollee does not have a history of problematic hypoglycemia with documentation of a history of a level 3 
hypoglycemic event. 
 
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 the enrollee does 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 Kit 2 sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre Kit 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reinstate the denture benefit. 
 
You asked the Plan to reinstate the denture benefit. You say that you cannot eat or drink with your current 
dentures and you need a new pair of dentures. The Plan denied your request. The Plan says your benefit for the 
requested 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 the Plan paid for dentures on February 27, 2023; therefore, your benefit for the requested item or service 
was exhausted on the date of service of February 27, 2023. Therefore, we decided that the Plan does not have 
to reinstate the denture benefit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve cataract removal. You say that you are only allowed to perform this surgery 
at two facilities. The Plan denied your request. The Plan says the elective procedure can be performed in a 
network facility when the schedule permits. 
 
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 
extracapsular cataract removal to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A9277). 
 
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 the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A9277).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient hospital care be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve outpatient hospital care. You say that you feel most comfortable with this 
doctor. The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 
outpatient hospital care be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you need a new denture. The Plan denied 
your request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a maxillary partial denture (D5213).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5213).  
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item was exhausted on date of service March 31, 2022. Specifically, the 
Plans contract states that one lower partial denture is covered every 60 months. You previously received this 
dental item on March 31, 2022, less than 60 months prior, which was paid for by the Plan.   
 
 
Therefore, you have exhausted the allowable benefit for this item. Therefore, we decided that the Plan does not 
have to pre-approve a lower partial denture (D5213).
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 September 16, 2022. 
 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the nurse 
from your health care provider told you to make the call. You also say that you assumed since they told you to 
call, they would cover the cost. 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 September 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist visit, and an injection provided 
on February 21, 2023. 
 
You asked the Plan to waive the cost share for a specialist visit and an injection. You say that you were 
unaware you would have to pay a copayment for the injection. 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 $30 
copayment for a specialist visit and 20% coinsurance for Medicare Part B drugs.   
You have been asked to pay $210 for a specialist visit and an injection. This total includes a $30 copayment for 
the specialist visit and $180 for the injection ($900 allowed amount x 20% = $180). The specialist visit falls 
with the physician visits benefit category. The injection falls within the Medicare Part B prescription drugs 
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 a specialist visit, and an injection 
provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items was exhausted on date of service May 20, 2021.  
  
 
Specifically, the Plans contract states that one upper and one lower complete denture is covered every 60 
months. You previously received these dental items on May 20, 2021, less than 60 months prior, which were 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for the requested items at this time. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid services (V5299) purchased 
on January 4, 2023. 
 
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 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aid services (V5299) purchased on 
January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM). 
 
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 the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 8),  prefabricated abutmentsincludes modification and placement (D6056 x 8), and implant 
supported crowns-porcelain fused to high noble alloys (D6066 x 8). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested dental items/services 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 requested items and services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of an implant body: endosteal implants (D6010 x 8),  prefabricated abutmentsincludes 
modification and placement (D6056 x 8), and implant supported crowns-porcelain fused to high noble alloys 
(D6066 x 8).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the submitted medical records support the need for 
IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for osteomyelitis and right 5th ray amputation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.