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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader and sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 14 day reader and sensor kit. You say that the enrollee is 
in a lot of pain and can only prick her right hand, not the left, because of her bilateral mastectomy. You also say 
that she has severe arthritis. The Plan denied your request. The Plan says the enrollee does not require insulin 
three or more times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 14 day reader and sensor kit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 14 day reader and sensor kit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 15, 
2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy was not 
diagnostic. 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 $325 
copayment for in-network outpatient surgery including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the colonoscopy. This item/service falls within the in-
network outpatient surgery including services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The medical records show 
you had a diagnostic colonoscopy. Therefore, we decided that the Plan does not have to waive the copayment 
for the colonoscopy provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 5, 2023, to January 24, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you acquired an 
infection after surgery. 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 $225 
copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 of inpatient care. 
 
 
 You have been asked to pay a $225 copayment per day, for days 1 to 7 of the inpatient hospital stay. You have 
been asked to pay a total of $1,575 ($225 copayment x 7 days = $1,575). You have not been charged for any 
additional days. 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 the inpatient hospital stay provided from January 5, 2023, to January 
24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 
13, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that this colonoscopy should be fully 
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 $200 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $200 copayment for the colonoscopy. This item/service falls within the 
outpatient surgery, including services provided at ambulatory surgical centers 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 record shows this was a high-risk 
colonoscopy screening, which falls under outpatient surgery. Therefore, we decided that the Plan does not have 
to waive the copayment for the colonoscopy provided on September 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 12, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) and 
supplies to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you are appealing the denied CGM and 
supplies. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered and are not covered when provided by an out-of-network provider.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the CGM and supplies and the requested provider is an out-of-network provider. Therefore, we decided that 
the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) and supplies to be 
provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy visits to be provided by an OON provider. You say that 
you called the Plan and were told the provider was in-network, so you should not have to pay the billed 
charges. The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 24, 2022, to July 
23, 2022. 
 
You asked the Plan to pay for home health services. You say that home health services were needed. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 24, 2022. The NOA was not received by the Plan until November 18, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 24, 2022, to July 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110), oral hygiene instructions 
(D1330), and comprehensive oral evaluation - new or established patient (D0150) provided on February 14, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the office staff told you that your dental claims 
are not being paid.  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.  
 
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.  Therefore, we decided that the Plan does not have 
to pay for prophylaxis - adult (D1110), oral hygiene instructions (D1330), and comprehensive oral evaluation - 
new or established patient (D0150) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments  
(98943 x 2) and the mechanical traction therapy (97012 x 2) provided on October 19, 2022 and October 26, 
2022. 
 
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 services provided are not a covered benefit 
by Medicare or the Plan.  
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments (98943 x 2) and the 
mechanical traction therapy (97012 x 2) provided on October 19, 2022 and October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provisional implant crown (D6085) provided on January 5, 
2023. 
 
You asked the Plan to pay for provisional implant crown. 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 
provisional implant crown (D6085) provided on January 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 24, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on January 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 2, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the submitted medical records 
support the service. The Plan denied your request. The Plan says the provider does not work with the enrollee's 
plan. 
 
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 subsequent nursing facility care provided on 
January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are necessary in order for you 
to get back to your full mobility and running. You also say that you have a long history of depression and 
anxiety, and running is very important to your physical and mental health. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #7 and #9 and retainer crowns 
(D6740) for tooth #6, #8, #10, and #11. 
 
You asked the Plan to pre-approve the dental services. You say that the dental devices were approved in 
September 2022, and they were never completed. The Plan denied your request. The Plan says your benefit for 
the requested items or services 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 the Plan approved pontics (D6245) for tooth #7 and #9 and retainer crowns (D6740) for tooth #6 and #8 
on January 31, 2022; therefore, the enrollees benefit for the requested items or services was exhausted on the 
date of approval of January 31, 2023. Therefore, we decided that the Plan does not have to pre-approve pontics 
(D6245) for tooth #7 and #9 and retainer crowns (D6740) for tooth #6, #8, #10, and #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown, porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve a crown. 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 pre-approve 
crown, porcelain/ceramic (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hospital clinic visit provided on 
January 09, 2023. 
 
You asked the Plan to waive the coinsurance for the hospital clinic visit. You say that the service is not listed in 
the Evidence of Coverage. 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 10% 
coinsurance for in-network outpatient hospital services. 
 
You have been asked to pay 10% coinsurance for the hospital clinic visit. This item/service falls within the in-
network outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $11.20 ($112 allowed amount x 10% = $11.20). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the hospital clinic visit provided on 
January 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment  includes placement (D6057) 
and abutment supported porcelain/ceramic crown (D6058) provided on January 5, 2023. 
 
You asked the Plan to pay for dental services. You say that you believe the services should be covered as you 
were not made aware of any limitations to the comprehensive dental plan. The Plan denied your request. The 
Plan says these services are 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. Custom fabricated abutment  
includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) are not covered under 
the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6057 and D6058 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058) provided on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic supplies 
 
You asked the Plan to pre-approve diabetic supplies. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that the Plan must review and approve certain medical procedures and 
services before these procedures and services are provided. This review process is referred to as prior 
authorization (approval in advance) and is conducted by clinical staff in our Utilization Management (UM) 
Department. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not send over the requested Evidence of Coverage (EOC). 
Therefore, we decided that the Plan has to pre-approve diabetic supplies  
 
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.