Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued inpatient psychiatric services starting August 7, 
2023. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the continued services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 approve these services. Our reviewer says that the 
continued services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on July 20, 2023 with unspecified schizophrenia disorder, unspecified anxiety disorder, and cannabis 
dependence. Based on the submitted records, it is not expected that she will improve in a reasonable period of 
time beyond the dates in question, as she does not have suicidal or homicidal ideation or auditory or visual 
hallucinations. She is not showing dangerousness to self or others and is compliant with treatment. It does not 
appear that active treatment is taking place beyond the dates of service in question. The continued inpatient 
psychiatric services are not medically necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to approve continued inpatient psychiatric services starting August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on April 12, 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 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 May 3, 2022. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on April 12, 2023.
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 bone graft at time of implant placement (D6104) provided on December 16, 2022. 
 
You asked the Plan to pay for surgical placement of implant body and a bone graft. 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 surgical 
placement of implant body; endosteal implant (D6010) and bone graft at time of implant placement (D6104) 
provided on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not filed in a timely fashion. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until March 16, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on October 29, 2022. 
 You asked the Plan to pay for the ambulance transport services. You say that you are requesting 
reconsideration of the audit findings and request for refund for the above referenced claim. 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 October 29, 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 ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on October 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited orthodontic treatment of the adult dentition 
(D8040) provided on April 10, 2023. 
 
You asked the Plan to pay for the limited orthodontic treatment. You say that the orthodontic services were a 
result of an injury while on vacation. You also say that the services are not cosmetic and that the cost was 
unexpected. The Plan denied your request. The Plan says D8040 is not listed on the dental benefit grid as 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 a limited 
orthodontic treatment of the adult dentition (D8040) provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 7, 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 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 pay for dental services provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110). 
 
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 on date of service January 24, 2023. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement #18, 
#19 (D6057) and abutment supported porcelain/ceramic crown #18, #19 (D6058). 
 
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 custom fabricated abutment  includes placement #18, #19 (D6057) and abutment 
supported porcelain/ceramic crown #18, #19 (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that you are requesting 
reconsideration and this should be made as easy as possible. The Plan denied your request. The Plan says you 
are requesting a CGM product that does not meet Medicare's definition of durable medical equipment (DME) 
and, therefore, is not in a defined Medicare benefit category. 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
March 3, 2023.  
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you were told to rebill 
as a routine. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 28, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for a determination of refractive state (92015) 
have not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive 
state (92015) provided on March 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional in-home support service hours.  
 
You asked the Plan to pre-approve the additional in-home support service hours. You say that you go through 
30 hours a month. You also say that you need these additional hours as you have end stage renal failure in 
addition to pulmonary edema and are insulin dependent diabetic.  The Plan denied your request. The Plan says 
it has been confirmed that you have used 61 hours between April 21, 2023 and June 21, 2023, therefore you are 
no longer eligible for this benefit.  We looked at the file and Medicare rules. You asked the Plan to pre-approve additional in-home support 
service hours. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of in-home support services. Therefore, we decided that the Plan does not have to pre-approve 
additional in-home support service hours.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow 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. Our reviewer says that the 
CGM coverage criteria was met. Our physician reviewer found that the enrollee is using insulin (is in the 
Soliqua medication), having low blood sugars, and has a hypertrophic cardiomyopathy. The enrollee is an ideal 
candidate for a CGM and meets coverage criteria. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide or lift.  
 
You asked the Plan to pay for a stair glide. You say that you would like reconsideration because the requested 
stair glide or lift is medically necessary. The Plan denied your request. The Plan says the requested stair glide 
or lift is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide or lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria, Pertussis vaccine provided on April 8, 
2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria, Pertussis vaccine. You say that it is medically necessary. 
The Plan denied your request. The Plan says the vaccine and its administration are covered under your Part D 
benefits.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria, 
Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria, Pertussis vaccine. Therefore, we decided that the Plan does not have to pay for Tetanus, Diphtheria, 
Pertussis vaccine provided on April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 20, 2023, 
to March 22, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 per day, for days 1 to 5 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last 
inpatient day. There were two days. 2 x $395 = $790. Therefore, results in the total cost sharing amount of 
$790. You have been asked to pay a $395 copayment per day for inpatient hospital 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 inpatient 
hospital stay on March 20, 2023, to March 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 30, 2022. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says this provider 
type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
November 30, 2022.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic obstructive pulmonary disease (COPD) with recurrent hospitalizations. An arterial blood gas on June 29, 2023 
showed mild compensated carbon dioxide retention. The pulmonary function tests confirm severe obstructive 
lung disease. The records do not show that the enrollee has tried and failed bi-level positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS). Medicare does not cover a home ventilator 
for this use and the services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump described by 
code E0218. 
 
You asked the Plan to pre-approve these services. You say that you are living alone and are afraid of falls. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The item at issue is a fluid circulating cold pad with pump described 
by code E0218. This item is denied by Medicare as not medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve a fluid circulating cold pad with pump described by code E0218.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid repair (V5014) provided on 
February 24, 2023. 
 
You asked the Plan to issue reimbursement 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 covered under 
the supplemental hearing aid policy.  
 
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 does not pay 
for hearing aid repairs.  
 
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 this service have not been met. Specifically, a hearing aid repair is not a covered benefit. 
Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aid repair (V5014) 
provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network skin biopsy provided on March 13, 
2023. 
 
You asked the Plan to waive the cost for an in-network skin biopsy. You say that you do not understand why 
you owe such a high amount for this service. 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 $300 
deductible and a $30 copayment for services from a specialist ($300 deductible + $30 copayment = $330). 
 
You have been asked to pay a $330 cost for an in-network skin biopsy. This item/service falls within the 
services from a specialist benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost for an in-network skin biopsy provided on March 13, 2023.