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

 
We decided that the Plan does not have to pay for dental services provided on December 22, 2022. 
 
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 $1,000 annual maximum 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 December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck. 
 
You asked the Plan to pre-approve the MRI. You say that the advanced imaging is needed to evaluate for 
trigeminal neuralgia. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has trigeminal neuralgia and 
MRI of the face has been approved. There is no discussion in the records concerning the need for MRI of the 
neck. Medical necessity of MRI of the neck has not been established in the records provided. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2. You say that the medical records support the need for 
the CGM. The Plan denied your request. The Plan says the enrollee does not meet medical criteria for the 
FreeStyle Libre 2.  
 
The Plan follows 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 FreeStyle Libre 2. Our reviewer 
says that the FreeStyle Libre 2 is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. The enrollee has neither and we are not told why the 
Accu-Chek meter would not suffice for their needs at this time. Although the CGM may help, coverage criteria 
are not met 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 FreeStyle Libre 2 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride varnish (D1206) provided on March 6, 2023. 
 
You asked the Plan to pay for fluoride varnish. 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 fluoride 
varnish (D1206) provided on March 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility care after July 1, 2023. 
 
You asked the Plan to pre-approve continued skilled nursing facility care. You say that the enrollee still needs 
further skilled services to continue to get better. The Plan denied your request. The Plan says the SNF benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 23, 2023, 
to July 1, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility care after July 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy services provided from November 28, 2022, 
to December 5, 2022. 
 
You asked the Plan to pay for the therapy services. You say that the services are valid and billable. The Plan 
denied your request. The Plan says the requested services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The infrared therapy is a non-covered service per NCD guidelines. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for infrared therapy services provided from November 28, 2022, to December 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal 
canal, and contents (72148). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. You say that you have back pain causing 
burning in feet. The Plan denied your request. The Plan says you have not done six (6) weeks of physician 
directed treatment in the past three (3) months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 Magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found no compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 Magnetic resonance imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal, and contents 
(72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite on two surfaces, posterior 
(D2392), a resin-based composite on three surfaces, posterior (D2393), and a resin-based composite (D2331) 
provided on March 13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that it was your understanding that the 
provider accepted your insurance and therefore is in-network. 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 a resin-based composite on two surfaces, 
posterior (D2392), a resin-based composite on three surfaces, posterior (D2393), and a resin-based composite 
(D2331) provided on March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on March 06, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that the MRI 
was ordered as part of your follow-up treatment and 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $170 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $170 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic test 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 a magnetic resonance imaging (MRI) provided on March 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 15, 2022, billed 
with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 81311, 
81317, 81320, 81321, 81334, 81339, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Pan to reconsider their 
denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 15, 2022, billed with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 
81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported mandibular removable denture 
(D6111). 
 
You asked the Plan to pre-approve an implant supported mandibular removable denture (D6111). You say that 
your old implants are kind of loose. You also say thats why you need the treatment of the support. The Plan 
denied your request. The Plan says this service is not covered in your dental 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 pre-approve an 
implant supported mandibular removable denture (D6111).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were told 
you would be reimbursed the $250 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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 a 
magnetic resonance image (MRI) provided on April 04, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 11, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was given to you in the emergency 
room and was not self-administered. 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 self-administered drugs provided 
on April 11, 2023.  
 
Benefits for the medication 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services requested are not related to 
previous care visits. The Plan denied your request. The Plan says the requested services are not medically 
reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for the patients condition. The services do not require the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist or under the supervision of a therapist. The specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
patient's current condition or to prevent or slow further deterioration. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor kit. The Plan denied your request. The Plan 
says based on the information provided on appeal you do not meet criteria for the CGM. 
 
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. Medicare rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish 
to the intermediary or carrier sufficient information to determine whether payment is due and the amount of 
payment. 
 
We looked at the file and Medicare rules. The documentation indicates that you are not insulin treated. The 
Plan provided evidence that there have been no pharmacy claims submitted for insulin. The Plan also provided 
evidence of reasonably attempting to obtain medical records. There have been no records submitted to 
demonstrate that you are being treated within insulin.  Based on this information, we decided that Medicare 
rules for coverage of the FreeStyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 2 sensor kit.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 26, 2023. 
 You asked the Plan to pay for the lab services. You say that the records provided support medical necessity. 
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 laboratory services provided on January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will get more deconditioned if you stay in the 
hospital any longer. You say that the hospital does not have enough help to assist you with getting out of bed. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can 
be provided safely in other settings.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, any joint of 
lower extremity (73721). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. You say that an MRI is necessary, as stated 
in the records herein. The Plan denied your request. The Plan says the medical records do not show the enrollee 
has completed six weeks of provider-directed treatment within the past three months without improved 
symptoms, and there was no contact with provider after completing treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 Magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found no compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 Magnetic resonance imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, any joint of lower extremity 
(73721).