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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and receiver 
(E2103, A4239). 
 
You asked the Plan to pre-approve the CGM and receiver. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as you do not 
meet the clinical requirements to be approved. 
 
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 the CGM and receiver. Our physician 
reviewer found that the record does not indicate you are on insulin or have a history of problematic 
hypoglycemia. Criteria are unmet. 
 
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 CGM and receiver have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and receiver (E2103, A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy and acupuncture 
services provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy and acupuncture services. You say that 
you think that the copayment should be lower. 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 $40 
copayment for Medicare-covered physical, occupational and speech therapy visits, and a $10 copayment per 
visit for acupuncture services. 
 
You have been asked to pay a $40 copayment for the physical therapy services. These items/services fall within 
the outpatient rehabilitation services benefit category. You have also been asked to pay a $10 copayment for 
the acupuncture services. These items/services fall within the acupuncture for chronic low back pain 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 the physical therapy and acupuncture services 
provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on May 
24, 2023. 
 
You asked the Plan to pay for the therapeutic exercise. You say that the service you received should be covered 
by your insurance. The Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) provided on November 7, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your coverage does not provide for these services. 
 
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 standard frames and lenses for cataracts up to the Medicare allowed amount. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan only covers standard frames and 
lenses for cataracts up to the Medicare allowed amount. The Plan rules also say that upgrades such as deluxe 
frames, progressive lenses, and additional lens upgrades (including but not limited to transition, scratch 
resistant, or tinted lenses) are not covered for glasses/lenses after cataract surgery. Based on this information, 
we decided that the Plan's rules for coverage of progressive lenses (V2781) have not been met. Therefore, we 
decided that the Plan does not have to pay for progressive lenses (V2781) provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 13, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the 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 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 office visit provided on June 13, 2023, by an 
OON provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on September 16, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The 
Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided any medical records or documented 
attempts at obtaining medical records to determine if you met Medicare criteria for the ambulance transport. 
The provider is a contract provider with the Plan and these records should be in control of the Plan. Therefore, 
we decided that the Plan has to pay for the ambulance services provided on September 16, 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 the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), pulp vitality tests (D0460), endodontic therapy, anterior tooth (excluding final restoration) (D3310), 
cone beam CT capture and interpretation with field of view of one full dental arch  maxilla, with or without 
cranium (D0366), and resin-based composite - one surface, anterior (D2330) provided on June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the plan provided a list of in-network providers 
and the one you selected was no longer with the practice listed on the plan provided forms. You also say that 
you located the new practice to receive treatment for your tooth infection. The Plan denied your request. The Plan says your benefit for the requested item or service $2,000 dollar limit 
was met. 
 
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 services was exhausted. The records indicate that the Plan paid $716 for 
date of service January 19, 2023, $131 for date of service June 7, 2023 and $1,1153 for date of service June 13, 
2023 was applied toward your $2,000 annual maximum. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230), pulp vitality tests (D0460), 
endodontic therapy, anterior tooth (excluding final restoration) (D3310), cone beam CT capture and 
interpretation with field of view of one full dental arch  maxilla, with or without cranium (D0366), and resin-
based composite - one surface, anterior (D2330) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on May 3, 2023. 
 
You asked the Plan to pay for the office visit. You say that you should not have to pay for the office visit. The 
Plan denied your request. The Plan says this service is not covered by your insurance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on June 19, 2023. 
 
You asked the Plan to pay for the debridement. You say that you are requesting reconsideration of the denied 
claim. 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 the debridement 
provided on June 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided 
from April 18, 2023, to April 28, 2023. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that this was the same 
facility as your previous inpatient stay, and it should only have a single copayment. 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 $395 
copayment for each inpatient rehabilitation stay.  
 The records show you were transferred to a different level of care, and a separate inpatient copayment applies. 
You have been asked to pay a $395 copayment for the inpatient rehabilitation stay. This item/service falls 
within the inpatient hospital care 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 
the inpatient rehabilitation stay provided from April 18, 2023, to April 28, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the esophagogastroduodenoscopy (EGD) provided by 
an in-network provider on May 26, 2023. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy (EGD). You say that this 
procedure was not performed. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $290 copayment for each in-network Medicare-covered 
outpatient hospital facility visit. 
 
The Plan says you must pay a $290 copayment for the esophagogastroduodenoscopy (EGD). Based on the Plan 
contract, however, you cannot be asked to pay more than a $290 copayment for the 
esophagogastroduodenoscopy (EGD) since the service was not performed. Therefore, we decided that the Plan 
has to waive the copayment for the esophagogastroduodenoscopy (EGD) provided by an in-network provider 
on May 26, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage.  
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 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 72 one-way transportation trips when each one-way trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. 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 mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that you were the only provider available to 
render medically necessary services. 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 an office visit provided 
on June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.  
You asked the Plan to pre-approve a CGM and supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from December 9, 2020, to January 7, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not understand 
the cost sharing. 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 each day, for days 1 to 6, for in-network Medicare-covered hospital care. 
 
 You have been asked to pay a $1186.51 copayment for the inpatient hospital stay because the Plan is only 
holding you responsible for this amount which is less than the $295 copayment per day. This item/service falls 
within the inpatient hospital care 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 
the inpatient hospital stay provided by an in-network provider from December 9, 2020, to January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader.  
You asked the Plan to pre-approve a Freestyle Libre 14-day reader. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 a Freestyle Libre 14-day reader have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 14-day reader.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted Therefore, we decided that the Plan does not have to pay 
for dental services provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond fixed partial denture (D6930) provided 
on June 21, 2023. 
 
You asked the Plan to pay for re-cement or re-bond fixed partial denture. 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 re-cement 
or re-bond fixed partial denture (D6930) provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compressor provided on March 23, 2023, to April 
10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for pneumatic compressor. You say that you have submitted medical records for 
review of 
medical necessity. 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 pneumatic compressor provided on March 23, 
2023, to April 10, 2023, by an out-of-network (OON) provider.