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

 
We decided that the Plan does not have to pre-approve Dynarex BZK antiseptic towelettes (E1399). 
 
You asked the Plan to pre-approve Dynarex BZK antiseptic towelettes. You say that you need the wipes. The 
Plan denied your request. The Plan says incontinence supplies are not covered because they are disposable, 
non-reusable hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve Dynarex BZK antiseptic 
towelettes (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 16, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751) and a pontic (D6241). 
 
You asked the Plan to pre-approve a retainer crown and a pontic. 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 a 
retainer crown (D6751) and a pontic (D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 Sensor. You say that you need the glucose monitor 
because it helps you maintain a healthy hemoglobin. The Plan denied your request. The Plan says criteria for 
medical necessity have not been met. 
 
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 a Freestyle Libre Kit 2 Sensor. Our 
reviewer says that the service/item is not medically necessary. Our physician reviewer found you are not on 
insulin now and not having low blood sugar. Therefore, continuous glucose monitor criteria have not been 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 a Freestyle Libre Kit 2 Sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre Kit 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a secondary blood test to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a secondary blood test . You say that one of your levels are high and the 
current lab/facility cannot tell you why. The Plan denied your request. The Plan says there are many other 
laboratories that are in-network who you need to see first. 
 
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 
a secondary blood test to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 pre-approve Xifaxan.   
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on January 30, 2023. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the patient is confused and has contractures. You also say that due to the patient's 
condition at the time of transport, any other means of transport would be unsafe. The Plan denied your request. 
The Plan says the ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport and ground mileage. Our reviewer says that the ambulance services were not medically 
necessary.  Our physician reviewer found the enrollee was admitted to the hospital on January 16, 2023 with sepsis with 
altered mental status. Intravenous fluids and antibiotics were administered. The enrollee failed a swallowing 
evaluation, and a percutaneous endoscopic gastrostomy  tube was placed. The enrollee was in stable condition 
and was discharged on January 30, 2023 to a skilled nursing facility to continue 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 the ambulance service, basic life support, emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, emergency transport and ground mileage provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 14, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames, the bifocal lenses, the progressive lenses, 
the polycarbonate lens, the tint, and the anti-reflective coating provided on February 3, 2023. 
 
You asked the Plan to pay more for  the progressive lenses, the polycarbonate lens, the tint, and the anti-
reflective coating . You say that you are appealing this denial. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
We looked at the file and the Plan's rules. Specifically, the frames and bifocal lenses were processed correctly 
in claim number IHO00825461. However, the remaining services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage for the progressive lenses, the polycarbonate lens, the 
tint, and the anti-reflective coating  have not been met. Therefore, we decided that the Plan does not have to 
pay more for the frames, the bifocal lenses, the progressive lenses, the polycarbonate lens, the tint, and the anti-
reflective coating provided on February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound repair service provided on 
March 29, 2022. 
 
You asked the Plan to waive the copayment for the wound repair service. You say that you already paid $60 on 
the date of service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $175 copayment for the wound repair service. This item/service falls within the 
outpatient surgery provided at an ambulatory surgical center 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 wound repair service provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed to show safety and efficacy. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted special service.  
 
You asked the Plan to pre-approve the unlisted special service. You say that you would like the quarterly 
benefit to be reinstated since you never used the benefit. You say you were never advised of this benefit. The 
Plan denied your request. The Plan says the over-the-counter benefit allowance per quarter cannot be carried 
over to another quarter. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit because the benefit allowance cannot be carried over to another quarter. Therefore, 
we decided that the Plan does not have to pre-approve the unlisted special service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7310), removal of residual tooth roots 
(D7250) and extractions (D7210). 
 
You asked the Plan to pre-approve alveoloplasty, removal of residual tooth roots and extractions. 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 
alveoloplasty (D7310), removal of residual tooth roots (D7250) and extractions (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the MRI provided on April 8, 2022, the 
specialist office visits provided from May 11, 2022, to October 12, 2022, the arthroplasty provided on July 7, 
2022, and the x-rays provided on July 13, 2022, and August 17, 2022. 
 
You asked the Plan to waive the copayments for the MRI, the specialist office visits, the arthroplasty, and the 
x-rays. You say that you cannot afford the copayments. 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 for each Medicare-covered diagnostic radiology service, including MRIs. Your contract with the 
Plan also clearly says that you must pay a $35 copayment for physician specialist services. Your contract with 
the Plan also clearly says that you must pay a $25 copayment for each Medicare-covered x-ray. Your contract 
with the Plan also clearly says that you must pay a $225 copayment for each Medicare-covered outpatient 
surgery at an outpatient hospital facility. 
 
You have been asked to pay a $217.87, which is less than the standard copayment for the MRI provided on 
April 8, 2022. You have also been asked to pay a $25 copayment for each x-ray provided on July 13, 2022, and 
August 17, 2022. These items/services fall within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. You have also been asked to pay a $35 copayment for each specialist office visit 
provided on May 11, 2022, June 29, 2022, and October 12, 2022. These items/services fall within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $225 copayment for the arthroplasty provided on July 7, 2022. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 copayments for the MRI provided on April 8, 2022, the specialist office visits 
provided from May 11, 2022, to October 12, 2022, the arthroplasty provided on July 7, 2022, and the x-rays 
provided on July 13, 2022, and August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the portable oxygen system and the 
oxygen concentrator provided on January 1, 2023, and February 11, 2023. 
 
You asked the Plan to waive the coinsurance for the portable oxygen system and the oxygen concentrator. You 
say that you were told the Plan was not going to pay. 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 20% 
coinsurance for durable medical equipment 
 
 
 You have been asked to pay $3.46, which is 20% coinsurance of the allowed amount for each portable oxygen 
system provided on January 11, 2023, and February 11, 2023 ($17.29 allowed amount x 20% = $3.46). You 
have also been asked to pay $14.05, which is 20% coinsurance of the allowed amount for each oxygen 
concentrator provided on January 11, 2023, and February 11, 2023 ($70.23 allowed amount x 20% = $14.05). 
These items/services fall within the durable medical equipment and related supplies 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 coinsurance for the portable oxygen system and the oxygen concentrator 
provided on January 1, 2023, and February 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor.  
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not on insulin. 
 
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 the enrollee does use insulin. Based 
on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your $1,000 annual maximum has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a crown porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the CPAP device provided on February 21, 
2023. 
 
You asked the Plan to reduce the deductible for the CPAP device. You say that you should only have a 10% 
coinsurance. 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 $750 deductible which applies to durable medical equipment and 
related supplies.  
 
 
 
 You have been asked to pay $39.75 towards the deductible for the CPAP device. The item or service you asked 
the Plan to reduce the deductible for falls within the durable medical equipment and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to durable medical equipment and related supplies. This cost sharing is a contractual 
obligation that had not been met at the time the CPAP device was received on February 21, 2023. Therefore, 
we decided that the Plan does not have to reduce the deductible for the CPAP device provided on February 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
each additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided on 
December 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should have been 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), each additional radiographic image (D0230), and bitewings - four radiographic images (D0274) 
provided on December 9, 2022.