Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
February 24, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on February 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0495, G0496, Q5001) provided from 
May 28, 2022, to June 26, 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 and the untimeliness was due to an issue with billing. 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 May 28, 2022. The NOA was not received by the Plan until December 12, 
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 (G0495, 
G0496, Q5001) provided from May 28, 2022, to June 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve the drug. You say that the enrollee has osteoporosis and has tried Prolia in 
the past with no positive outcomes. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that 
Evenity is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs alendronate, ibandronate, pamidronate, risedronate, and zoledronic acid. Also, there is no 
indication that the Plan's required drugs would likely be less effective or likely have adverse effects for the 
enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), maxillary partial denture 
(D5213), retainer crown (D6750), and a pontic (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950), maxillary partial denture (D5213), retainer crown (D6750), and 
a pontic (D6240).
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown on tooth # 11 and # 13 (D6751) and a 
pontic on tooth #12 (D6211). 
 
You asked the Plan to pre-approve retainer crown and a pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says this service is denied because the documentation provided does not 
demonstrate any specific physical or neurological need or condition that precludes the use of a removable 
prosthesis. 
 
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. The Plan covers retainer 
crown and a pontic when the services are medically necessary and reasonable.  
 
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 retainer crown and a pontic. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
provided was incomplete.  The required radiographs were not submitted to determine if there were other 
missing teeth in the arch.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and a pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown on tooth # 11 and # 13 (D6751) and a pontic on tooth #12 
(D6211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM system to be provided by an OON provider.  
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the denial of the CGM. 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 
a CGM system to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81518) provided on April 20, 2023. 
 
You asked the Plan to pay for the laboratory services (81518). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. Unless a 
specific exception is met, laboratory claims should be reported with the date of service the specimen was 
collected. 
 
We find that the reported date of service of April 20, 2023, is not supported in the medical record. Specifically, 
the records do not indicate what date the sample was obtained from storage, which would be the correct date of 
service to report on the claim. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81518) provided on April 
20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed (E0250) purchased on April 17, 2023, from 
a provider that is not certified with Medicare. 
 
You asked the Plan to pay for the hospital bed. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital bed (E0250) purchased on 
April 17, 2023, from a provider that is not certified with Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to be able to ambulate and perform daily living tasks without assistance in order to return home safely. The 
Plan denied your request. The Plan says the enrollee does not meet the 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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve the Dexcom G6 transmitter. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered. You did not tell us why the enrollee cannot 
use the Plan's preferred CGM system. 
 
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 Dexcom G6 transmitter. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
transmitter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary and the best 
treatment option for the best recovery for the enrollee to have the best quality of life. The Plan denied your 
request. The Plan says the enrollee does not meet the 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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia (D9222/D9223). 
 
You asked the Plan to pre-approve D9222 and D9223. You say that anesthesia was medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 
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 
general anesthesia (D9222/D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve chiropractic manipulative treatment. You say that you are seeking more 
services. You say that your Health Plan would not pay for your services if you did not come back-to-back 
every day for two weeks. The Plan denied your request. The Plan says chiropractic manipulative treatment is 
not medically necessary.  
 
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.  
 
  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 chiropractic manipulative treatment. 
Our reviewer says that chiropractic manipulative treatment is not medically necessary. Our physician reviewer 
found that you have foot drop, neck pain, and low back pain. However, the records do not document the 
presence of subluxation either by physical examination or radiographic images. Therefore, the elements of the 
coverage criteria are not satisfied, and the service is not 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 chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic manipulative treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver and sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 receiver and sensor. The Plan denied your request. The Plan 
says the enrollee is not receiving insulin and has not had a documented hypoglycemic episode. 
 
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 Dexcom G6 receiver and sensor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 receiver and sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair (49505), provided on March 13, 2023. 
 
You asked the Plan to pay for the hernia repair. You say that the services should be covered. The Plan denied 
your request. The Plan says since the provider is out of network, the Plan allows/pays at the maximum 
allowable fee (MAF). The MAF is the rate at which we pay in network providers. If members choose to use out 
of network providers, they are responsible for the difference between MAF and billed charges. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The service was obtained out-of-network and the Plan paid the allowable rate for this service. Therefore, we 
decided that the Plan does not have to pay for the hernia repair (49505), provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve acupuncture treatments.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for the 
requested services in this case.  
 
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. Specifically, the Plans contract states that 6 visits of routine acupuncture 
services are covered each year. The Plan has stated that 6 routine acupuncture visits have been provided and 
covered for you this calendar year. However, the Plan has not provided proof of payment for these services. 
The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that 
the Plan has to pre-approve acupuncture treatments.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee suffers from bilateral 
knee pain due to advanced osteoarthritis in both knees. You say that the enrollee has tried and failed six months 
of conservative treatment, such as physical therapy and a daily home exercise program. The Plan denied your 
request. The Plan says the genicular nerve block is not medically necessary.  
 
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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is considered experimental and investigational. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.