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

 
We decided that the Plan does not have to waive the deductible for the oxygen concentrator provided on 
January 15, 2023. 
 
You asked the Plan to waive the deductible for the oxygen concentrator. You say that this item should be 
covered. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to durable medical equipment and 
related supplies.  
 
 
 
 You have been asked to pay $73.30 towards the deductible for the oxygen concentrator. The item or service 
you asked the Plan to waive the copayment for falls within the durable medical equipment and related supplies 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to durable medical equipment and related supplies. This cost sharing is a contractual 
obligation that had not been met at the time the oxygen concentrator was received on January 15, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the oxygen concentrator provided 
on January 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on October 
21, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you thought this service falls 
under the specialist office visit benefit category. 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 $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 copayment for the urgent 
care visit provided on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
January 06, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services 
should be covered. 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 a home visit for the 
evaluation and management provided on January 06, 2023.
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 February 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be responsible for the amount since you just fell and was not actually transported to the hospital. 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 February 12, 2023. 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 February 12, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) 
provided on October 6, 2022. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this is a covered code.  
The Plan denied your request. The Plan says that ordering a multi-class panel of definitive (confirmation) urine 
drug tests that are not used in clinical management, exceeds the needs of the enrollee. Under Medicare rules, 
the number of definitive urine drug classes requested are not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that UDT is covered when medically necessary according 
to the rules in the LCD. 
 
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 pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that this testing was medically necessary. Our physician reviewer found that the enrollee had 
cannabinoids in urine which were not prescribed. Definitive testing was therefore, indicated. The testing was 
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 the definitive UDT for 15-21 drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) 
provided on October 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination provided on March 20, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the eye exam. You say that the provider relies on the nursing facility to obtain 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 did not pre-approve the 
eye examination. We found no exception that would require the Plan to pay for the eye examination. Therefore, 
we decided that the Plan does not have to pay for the eye examination provided on March 20, 2023, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensors. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensors. You say that you believe the enrollee has 
been able to stay off insulin by monitoring and adjusting diet and exercise. You also say that the enrollee has an 
essential tremor which makes using a standard glucometer impossible. The Plan denied your request. The Plan 
says it was determined that the enrollee is not insulin-treated nor have a history of problematic hypoglycemia. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve FreeStyle Libre 2 sensors.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
January 06, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that polyps were removed, 
but it was a preventative procedure. 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 $100 
copayment for outpatient surgery. 
 
You have been asked to pay a $100 copayment for the diagnostic colonoscopy. This item/service falls within 
the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The medical records show you had polyps removed during your colonoscopy. According 
to the EOC, if polyps were removed during a colonoscopy, the procedure is considered diagnostic. Therefore, 
we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
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 dental 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 November 10, 2021. Specifically, 
the Plans contract states that one complete lower denture is covered every 60 months. You previously received 
this dental item on November 10, 2021, less than 60 months prior, which was paid for by the Plan.   
 
 
Therefore, you have exhausted the allowable benefit for the requested dental item in this case. Therefore, we 
decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. The Plan denied your request. The Plan says a home ventilator is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met.  Our physician reviewer found a home ventilator is not medically necessary.  This enrollee has very severe obesity, obstructive sleep apnea, and obesity 
hypoventilation syndrome.  Pulmonary function testing shows mild obstructive lung disease.  There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease.  A sleep study with positive airway pressure 
(PAP) titration showed that continuous positive airway pressure (CPAP) and bilevel positive airway pressure 
(BiPAP) did not resolve the elevated end-tidal carbon dioxide (CO2) or hypoxemia.  The enrollee did the best 
with average volume assured pressure support (AVAPS) and supplemental oxygen.  AVAPS can be provided 
with certain BiPAP devices.  There is no evidence in the record that this has been tried and failed as an 
outpatient.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 is not receiving the care 
needed in the current facility. The Plan denied your request. The Plan says the enrollee's medical needs are 
being met at the current facility.  
 
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. All medically necessary care is being provided in the 
current acute care setting.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 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 items1 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).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of the implant body (D6010), a 
custom abutment (D6057), and abutment supported to crown (D6058) for tooth #8. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the surgical placement of the implant body, a custom abutment, and abutment supported to crown are 
not covered by the 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 the 
surgical placement of the implant body (D6010), a custom abutment (D6057), and abutment supported to 
crown (D6058) for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM is medically 
necessary because the enrollee cannot prick their finger anymore. The Plan denied your request. The Plan says 
the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies. 
 
You asked the Plan to pre-approve diabetic supplies. You say that these diabetic supplies are medically 
necessary. The Plan denied your request. The Plan says medical records were not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 diabetic supplies have been met. Multiple attempts were made to obtain medical records for the enrollee with no success. Therefore, we decided 
that the Plan does not have to pre-approve diabetic supplies.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a lower partial denture (D5214). 
 
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 that you have exhausted the allowable benefit for the 
requested dental item. 
 
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 Plan has stated that a lower partial denture is covered every 60 
months. The Plan has indicated that you have exhausted the allowable benefit for the requested dental item in 
this case. However, the Plan has not provided substantive evidence that demonstrates you have exhausted this 
benefit. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve a lower partial denture (D5214).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this stay was the result 
of a provider's mistake. 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 $290 
copayment per day for days 1-6 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says you then pay a $0 copayment per day for days 7-365 of each in-network inpatient hospital stay. You have been asked to pay a $290 copayment per day for day one of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day one 
or for the day you were discharged. 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 from January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unspecified removable prosthodontic procedures 
(D5899). 
 
You asked the Plan to pre-approve the dental services. You say that the mouthpiece is needed to keep your 
mouth in place. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the unspecified removable prosthodontic procedures are not covered by the 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 the 
unspecified removable prosthodontic procedures (D5899).