Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboraotory services, the dialysis procedure, the medical 
supplies, and the cinacalcet medication provided on June 05, 2023, to June 30, 2023. 
 
You asked the Plan to pay for the laboraotory services, the dialysis procedure, the medical supplies, and the 
cinacalcet medication. You say that you are requesting reconsideration of the denied claim. 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 the laboraotory services, 
the dialysis procedure, the medical supplies, and the cinacalcet medication provided on June 05, 2023, to June 
30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 27, 2023, to May 01, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you say that you had a 
bad and horrible experience at the facility and they mistreated you as a patient. 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 inpatient hospital coverage.  
You have been asked to pay a $250 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital coverage 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. You have been asked to pay a total of $750 for the inpatient hospital stay ($250 copayment 
x 3 days = $750). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on April 27, 2023, to May 
01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 5, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 5, 2023.
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 have been trying to get your 
A1C under 7 for a long time. You also say it was suggested to try the FreeStyle 3 sensor with Ozempic because 
it has gotten a lot of patients to a better control of the A1C. The Plan denied your request. The Plan says the 
clinical information submitted along with your prescription drug plan benefits criteria has not been met. The 
Plan also verified with your physician's office you are not using insulin or have problematic hypoglycemia. 
 
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. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for coverage 
of the FreeStyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 3 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (luspatercept-aamt J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that you are requesting a fast appeal because your next 
injection is due on November 9, 2023. The Plan denied your request. The Plan says the requested use of this 
drug is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Reblozyl. Our reviewer says that the 
requested use of Reblozyl is not supported. Our physician reviewer found the use of Reblozyl in high risk 
myelodysplastic syndrome (MDS) is not reasonable or medically necessary. The Food and Drug 
Administration has not stated that the requested drug is indicated for your specific condition. The requested use 
of Reblozyl is also not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (luspatercept-aamt J0896).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation provided on March 17, 2023. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that you are requesting reconsideration of the 
denied claim. 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 the psychiatric 
evaluation provided on March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for hospital services provided on January 10, 
2023. 
 
You asked the Plan to waive the cost share for hospital services. You say that you disagree with the cost share. 
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 a $800 deductible which applies to hospital services.  
 
The item or service you asked the Plan to waive the cost share for falls within the hospital services benefit 
category. You are being asked to pay $632.58 towards your $800 deductible. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $800 deductible which applies to hospital services. This 
cost sharing is a contractual obligation that had not been met at the time hospital services was received on 
January 10, 2023. Therefore, we decided that the Plan does not have to waive the cost share for hospital 
services provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0671). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the documentation does not show the response to 
treatment from the requested pump. The documentation does not include pre-trial and post-trial measurements 
of both legs. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0671).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (49329, 47379) provided on May 30, 2023. 
 
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 49329 and 47379 are not supported in the medical record. Specifically, unlisted codes 
were incorrectly billed with the -79 modifier. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (49329, 47379) provided on May 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan pre-approve the additional trips. You say that you need the extra trips for your radiation 
treatments. You also say that you and your husband are unable to drive. The Plan denied your request. The Plan 
says the record shows you have already met your maximum number of one-way trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your radiation appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have pre-approve additional routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and related pain 
management services provided on January 24, 2023, to March 31, 2023, by an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment and related pain management services. 
You say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan 
says the service was not authorized. 
 
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 chiropractic manipulative treatment and 
related pain management services provided on January 24, 2023, to March 31, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver, sensor and transmitter. 
 
You asked the Plan to pre-approve the Dexcom G6 receiver, sensor and transmitter. You say that you need this 
to help with your type 2 diabetes. The Plan denied your request. The Plan says you are not receiving insulin 
and have not had a documented hypoglycemic episode. 
 
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. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the Dexcom G6 receiver, sensor and transmitter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 receiver, sensor and transmitter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2023, 
through June 4, 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 hospital care provided was 
not medically necessary.   
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was evaluated in the emergency department (ED) on June 3, 2023 and had a 
hernia reduced at bedside by General Surgery without complications. She was evaluated/observed overnight 
and was ultimately discharged home the next day. The review has determined that the record does not show 
that at the time of the inpatient admission it was reasonable for the admitting physician to expect that the 
enrollees necessary hospital care (including earlier ED and/or observation care) would span two midnights 
with supporting documentation of the enrollees history and comorbidities, signs and symptoms, current 
medical needs, and risk of an adverse event. 
 
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 hospital care provided from June 3, 2023, through June 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve freestyle blood glucose test strips (A4253). 
 
You asked the Plan to pre-approve the freestyle blood glucose test strips. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
 
  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 freestyle blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve 
freestyle blood glucose test strips (A4253).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you recently had a bad fall and have a high 
white blood cell count and would like the Plan to cover the service. You say that your doctor ordered the scan 
to make sure everything is okay. The Plan denied your request. The Plan says a PET scan is not medically 
necessary.  
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that a 
PET scan is not medically necessary. Our physician reviewer found that you are not suspected of having either 
AD or FTD as there is only mention of a mild cognitive impairment (MCI). Therefore, the base requirements of 
the NCD coverage criteria are not met. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you have  doctor appointments and do not 
have any trips left You also say that you are frustrated that you have run out of rides. The Plan denied your 
request. The Plan says the records show you have used 24 one-way trips of this service. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your doctor appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retreatment of a previous root canal therapy-premolar 
(D3347). 
 
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 covered under the 
supplemental dental policy.   
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retreatment 
of a previous root canal therapy-premolar (D3347).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of an erupted tooth or exposed root 
(D7140), add bone to the jaw (D7953), guided tissue regeneration (D4266), surgical placement of implant body 
(D6010), diagnostic casts (D0470), cone beam computed tomography (CT) image capture with field of view of 
both jaws (D0383), and surgical stent (D5982). 
 
You asked the Plan to pre-approve the dental services. You say that both general and specialty providers are 
limited in your area. You also say you contacted the offices in your area and were not able to locate any 
periodontist that can complete this service. The Plan denied your request. The Plan says dental services from an 
out-of-network provider 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.  
You are requesting 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 pre-approve the 
extraction of an erupted tooth or exposed root (D7140), add bone to the jaw (D7953), guided tissue 
regeneration (D4266), surgical placement of implant body (D6010), diagnostic casts (D0470), cone beam 
computed tomography (CT) image capture with field of view of both jaws (D0383), and surgical stent (D5982).