Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on August 3, 2023. 
 You asked the Plan to pay for the transportation services. You say that the enrollee was not on hospice at the 
time of transport. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the transportation services provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the administration of influenza virus vaccine provided on 
February 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the administration of influenza virus vaccine. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says that the administration of influenza virus vaccine is 
available in network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the administration of influenza virus vaccine 
provided on February 13, 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 a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. 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 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. Specifically, the prescriber fax form from the enrollees treating 
physician 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 CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, of the sacroiliac joint, percutaneous, 
with image guidance (0775T). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no sacroiliac joint instability, fracture, or lesion. Sacroiliac joint fusion for degenerative  
back pain is considered experimental. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, of the sacroiliac joint, percutaneous, with image guidance (0775T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an eye examination (92014) provided on 
May 25, 2023. 
 
You asked the Plan to waive the deductible for an eye examination (92014). You say that there are few 
providers in your area. You also say you are established with this provider. 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 40% coinsurance, after your $750 Plan deductible, which applies to 
each out-of-network non-Medicare covered eye examination and each follow-up diabetic eye examination.  
 
The item or service you asked the Plan to waive the deductible for falls within the each out-of-network non-
Medicare covered eye examination and each follow-up diabetic eye examination benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is 40% coinsurance, after your $750 
Plan deductible, which applies to each out-of-network non-Medicare covered eye examination and each follow-
up diabetic eye examination. This cost sharing is a contractual obligation that had not been met at the time an 
eye examination (92014) was received on May 25, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for an eye examination (92014) provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that to buy the hearing aids from in-network will cost 
the entire benefit. You also say this will leave you to pay the balance, which is a hefty sum as well. The Plan 
denied your request. The Plan says the service sought or obtained by the member was or will be rendered by a 
provider who is not under contract with the Plan. 
 
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 the hearing aids are obtained through a Plan hearing network provider. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for special supplemental benefits for the 
chronically ill (SSBCI).  
 
You asked the Plan to provide reimbursement for SSBCI benefits. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to 
provide reimbursement for special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet certain criteria. 
 
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 facet joint injections. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee meets the criteria for a 
therapeutic injection. The request is 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 facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve facet joint injections (64493, 64494).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate dentures, extractions, and unspecified removable 
prosthodontic procedure (D5130, D7210, D5899) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Additionally, this benefit does not include 
unspecified removable prosthodontic procedures. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider Additionally, this benefit does not include 
unspecified removable prosthodontic procedures.. Therefore, we decided that the Plan does not have to pay for 
immediate dentures, extractions, and unspecified removable prosthodontic procedure (D5130, D7210, D5899) 
provided on July 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
December 20, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are appealing the denied claim. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on December 
20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable chest x-rays provided on June 09, 2023. 
 
You asked the Plan to pay for portable chest x-rays. You say that these services were medically necessary. 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 portable chest x-rays 
provided on June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate sedation (D9239) provided on May 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the plan to pay for this. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount exhausted on date of service May 25, 2023. Any amount over 
$500 is the enrollees responsibility. Therefore, we decided that the Plan does not have to pay for intravenous 
moderate sedation (D9239) provided on May 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
March 10, 2023, through March 30, 2023.  
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was 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 pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on March 10, 2023 with Major 
Depressive Disorder, Recurrent, Unspecified, Anxiety Disorder Unspecified, Major Depressive Disorder, 
Recurrent, Severe without Psychotic Features, and Major Neurocognitive Disorder, Most Likely Due To 
Alzheimers Disease with Behavioral Disturbance. Based upon the review of the records provided, it was not 
expected that this enrollee would improve in a reasonable period of time as he did not have dangerousness to 
self or others, auditory and visual hallucinations, or delusions, and was not showing any behavioral issues. It 
did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual 
disturbance including delusions, or auditory and visual hallucinations. The health plans denial of inpatient 
psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health 
treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that 
active treatment was taking place. It did not appear that the services were reasonably expected to improve the 
enrollees condition or were for the purpose of a diagnosis. It did appear that the records were supervised and 
evaluated by a physician. Based upon the review of the records provided, the enrollee does not meet criteria for 
coverage of the acute inpatient mental health treatment provided as he was not shown to be a danger to himself 
or others, and did not have auditory or visual hallucinations. He was noted to be cooperative and compliant 
with treatment while not showing any aggressive behaviors as he awaited placement. 
 
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 pay for the acute inpatient psychiatric hospital care provided from March 10, 2023, through March 30, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 1, 2023, to 
August 15, 2023. 
 
You asked the Plan to pay for home health services. You say that you are a participating, in-network provider. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill is a required 4-digit 
alphanumeric code that gives two pieces of information. The first three digits indicate the base type of bill. The 
fourth digit indicates the sequence of this bill in this particular period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the services at issue have been reported on a Type of Bill with an invalid 4th digit. Therefore, we decided that the Plan does not have to pay for home health 
services provided from August 1, 2023, to August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on August 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to processed this 
at an in-network rate. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an out-of-
network provider on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on November 29, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the services were medically necessary. 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 wound care supplies 
provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac joint injection provided on July 6, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says that the sacroiliac 
joint injection is available in network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the sacroiliac joint injection provided on July 6, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on June 12, 2023. 
 
You asked the Plan to pay for the office visit. You say that you cannot pay the amount due because of financial 
hardship. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen equipment and the durable medical 
equipment purchased on June 5, 2023. 
 
You asked the Plan to pay for the portable oxygen equipment and the durable medical equipment. You say that 
you were under the impression that you could purchase the portable machine and be reimbursed. You say that 
you do not need to use the concentrator during the day and that you are not able to fly with the concentrator 
your provider provides. The Plan denied your request. The Plan says the purchased oxygen equipment is not a 
covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
equipment and the durable medical equipment purchased on June 5, 2023.