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

 
We decided that the Plan does not have to pay for a therapeutic CGM to include all supplies and accessories, 1 
month supply provided on November 15, 2022. 
 
You asked the Plan to pay for a therapeutic CGM, to include all supplies and accessories, 1 month supply. You 
say that you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says 
the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
provided did not meet the criteria which in this case the shipping/delivery date and the dates of service do not 
match. Therefore, we decided that the Plan does not have to pay for a therapeutic CGM to include all supplies 
and accessories, 1 month supply provided on November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on December 23, 2022. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that the ambulance 
service was needed as it was a life threatening situation. 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 December 23, 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 ambulance response and treatment with no 
transport provided on December 23, 2022.
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 enrollee will benefit from rehabilitation services.  
The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as a skilled nursing facility, home with home health services or home with outpatient therapy.  
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's complex medical 
needs, the LTACH level of care is the most appropriate to achieve the best outcome. The Plan denied your 
request. The Plan says the requested LTACH services do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Chemotherapy injection, denosumab 
provided on February 02, 2023. 
 
You asked the Plan to waive the coinsurance for Chemotherapy injection, denosumab. You say that you were 
unaware of the high cost share for the services rendered. 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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
You have been asked to pay 20% coinsurance for Chemotherapy injection, denosumab. This item/service 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. The total you owe is $520.39, which is 20% of the allowed 
amount for a Chemotherapy injection ($2,601.96 allowed x 20% = $520.39). Therefore, we decided that the 
Plan does not have to waive the coinsurance for Chemotherapy injection, denosumab provided on February 02, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310) provided on September 29, 2022. 
 
You asked the Plan to pay for dental services. You say that you feel this is not reasonable and not an acceptable 
denial. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Surgical placement of implant 
body: endosteal implant (D6010) and consultation - diagnostic service provided by dentist or physician other 
than requesting dentist or physician (D9310) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010 and D9310 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
surgical placement of implant body: endosteal implant (D6010) and consultation - diagnostic service provided 
by dentist or physician other than requesting dentist or physician (D9310) provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on August 30, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment. The 
Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) is not covered 
under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9310 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for consultation - 
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided 
on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
September 30, 2022, to December 09, 2022. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you were told you 
would not have a 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 $50 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for each specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including doctors office visits 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 total amount you owe is $250 ($50 
copayment x 5 visits = $250). Therefore, we decided that the Plan does not have to waive the copayment for 
each specialist office visit provided on September 30, 2022, to December 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the out-of-network eye exam  
You asked the Plan to pre-approve the eye exam. You say that the price is cheaper at the out-of-network 
provider. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 this service when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is out-of-network and in-network providers 
are available. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the out-of-network eye exam
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on September 17, 2022. 
 You asked the Plan to pay for subsequent hospital care. You say that the enrollee was not enrolled in hospice at 
the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 13, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on September 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see another provider for implant 
services. 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 date of service April 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on February 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that this is a covered benefit. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on October 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a Medicare-covered benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the rules say that there is sufficient evidence to 
conclude that the use of infrared therapy devices and any related accessories is not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on  
October 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drugs, self-administered. 
 
You asked the Plan to pay for Drugs, self-administered . You say that you paid you copay and all should be 
covered by your physicians referral. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for Drugs, self-administered.  
 
Benefits for Drugs, self-administered  may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician supervision 
for 20 sessions (G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician supervision for 20 sessions. You 
say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 
necessary as you have not been offloading consistently. 
 
The Plan follows Medicare rules. 
 
   
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 hyperbaric oxygen therapy with 
physician supervision for 20 sessions. Our reviewer says that you do not meet coverage criteria for this service. 
Our physician reviewer found the provided documentation did not clearly describe you with currently 
controlled diabetes, good vascular flow to the right foot/toe area and making all other lifestyle changes such as 
quitting smoking to improve the odds of HBO being helpful. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy with physician supervision for 20 sessions have not 
been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with 
physician supervision for 20 sessions (G0277, 99183).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show they need continued treatments 
and care that can only be given in a hospital setting. Their continued care needs include intravenous antibiotics 
and wound care. When they are ready to leave the hospital, they can safely receive this care in another setting, 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI performed on March 6, 2022, and 
September 1, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you believe the cost share applied is 
much higher than could be reasonably expected and the claim should be reprocessed. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for outpatient diagnostic tests.  
 
 
 The enrollee has been asked to pay a total copayment of $382.38 for an MRI. This total includes $191.53 for an 
MRI performed on March 6, 2022, and $190.85 for an MRI performed on September 1, 2022. The charges 
applied are less than the standard $200 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI 
performed on March 6, 2022, and September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary.  The Plan 
denied your request. The Plan says the documentation does not support the billed units.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism.  
 
 
 We find that 13 units of CPT code 87798 is not supported in the medical record. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87798 billed for date of service November 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Alendronate, Ibandronate, Risedronate, or 
Zoledronic Acid first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the case file does not support that the 
enrollee has tried and failed treatment with Alendronate, Ibandronate, Risedronate, or Zoledronic acid. The 
documentation does not support that Alendronate, Ibandronate, Risedronate, or Zoledronic acid would likely be 
less effective, and/or would likely have adverse effects for the enrollee in this case. Liver disease is not listed in 
Micromedex as a contraindication or a precaution for the use of Alendronate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.