Persius/hicric huggingface dataset:
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 the enrollee has cognitive impairments that impact 
his safety and care. The Plan denied your request. The Plan says it is not likely that the enrollee can fully 
participate in 3 hours of therapy per day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is generally medically stable. He had a recent stroke with main deficits as severe cognitive 
impairment and left sided neglect. There is no evidence of complex medical issues that require monitoring by 
an inpatient rehab physician three times per week, or a need for acute rehab nursing care. Currently, the 
enrollee still requires speech therapy and physical therapy for safety of his mobility. While the enrollee may 
benefit from continuing physical and speech therapy, there is no evidence of need for an intensive therapy 
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. Therefore, an admission to an IRF is not medically necessary based, on lack of medical 
complexity and his functional status. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee requires intensive rehab with daily 
physician visits to optimize mobility. The Plan denied your request. The Plan says the enrollee does not have a 
need for intensive rehab, physician supervision, or a multidisciplinary team for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is generally medically stable with no acute illness or complexity of medical problems, and no 
recent neurological or Orthopedic events. There is no evidence of complex medical issues that require 
monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. While 
the patient may benefit from continuing physical and occupational therapy, there is no evidence of need for an 
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. Therefore, an admission to an IRF is not medically necessary 
based on lack of medical complexity. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve these services. You say that you have issues with forward balance, no sense 
of taste and smell, and numbness in your feet to your knees. The Plan denied your request. The Plan says the 
services are available from network providers. 
 
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 referral to an out-of-network neurosurgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that physical therapy has been beneficial to your recovery. You say that by not doing the treatment you are set back. The Plan denied your request. The Plan says further therapy is not medically 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 additional physical therapy visits. 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 that you had extensive prior therapy and should be able to transition to a home exercise program. Our physician reviewer found that your current level of function does not require ongoing skilled therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this would improve your overall 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal emergency response system with auto detect 
fall and GPS capability (S5161). 
 
You asked the Plan to pre-approve personal emergency response system. You say that your current personal 
emergency response system is not as safe as this one. The Plan denied your request. The Plan says this item is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve personal emergency response system with auto detect fall 
and GPS capability (S5161).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you would like to travel and 
do not want to have to just stay home. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Review of the 
records shows that you were previously provided with a home oxygen system, including a home oxygen 
concentrator and size C portable oxygen tanks, for your oxygen needs within the home. The item at issue in this 
appeal performs the same function as equipment that you currently use for your oxygen needs within the home. 
Medicare does not pay for duplicative equipment and does not cover additional equipment for use outside the 
home and does not cover oxygen services furnished to a beneficiary by an airline. Therefore, we are upholding 
the request for a portable oxygen concentrator for travel and use outside of the home. Therefore, we decided 
that the Plan does not have to pre-approve portable oxygen concentrator, rental (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve face masks (E1399). 
 
You asked the Plan to pre-approve face masks. You say that the records provided should support the necessity 
of the requested service. The Plan denied your request. The Plan says face masks are not covered as they are 
not used to treat a medical condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve face masks (E1399).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the rehabilitation hospital services provided from October 23, 2019 to 
October 31, 2019. 
 
You asked the Plan to pay for the rehabilitation hospital services. You say that this was denied as no 
authorization, but you were not given the correct benefit information, so you were not able to request 
authorization from the plan. The Plan denied your request. The Plan says that payment is not allowed for this 
service because the Medicare ID number, NPI, and Taxonomy code are needed to process this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that billing provider information is entered into FL01 
of the CMS-1450 claim form. Pay-to information is entered into FL02 but is not required.  
 
In this case, the Plan was not specific about where the above noted missing information should have been 
found. Review of the electronic claim form readout provided by the Plan clearly shows that the Medicare ID 
number, NPI, and taxonomy code related to the NPI are all present in FL01 and elsewhere on the claim form. 
The only section in which this information is not reported is in the Pay-to Provider section. As mentioned in the 
rules, this section is not required. As such, we find no deficiency that would justify denial of this claim on the 
grounds presented by the Plan. Therefore, we decided that the Plan has to pay for the rehabilitation hospital 
services provided from October 23, 2019 to October 31, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture. 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you would like your lower 
denture replaced so you can eat properly and pronounce words. The Plan denied your request. The Plan says 
you have exhausted your denture benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to once per arch 
every 5 years. The record shows that you received a complete mandibular denture on April 16, 2018 and your 
mandibular dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a complete mandibular denture.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 27 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional transportation. You say that you do not have any form of 
transportation and you do not have enough money to pay for transportation. The Plan denied your request. The 
Plan says this request exceeds the benefit frequency limitation. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 27 additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 has network providers available who can provide 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 chiropractic services provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on March 24, 
2020. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
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 $60 
copayment for radiation therapy.  
 
You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
outpatient diagnostic tests and therapeutic services and 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 copayment for radiation therapy provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99220 and 99217) provided on April 2, 2020 through April 3, 2020.
You asked the Plan to pay for the observation care. You say that you would like reconsideration because the services rendered were emergent and payment is required. The Plan denied your request. The Plan says the ICD-10 manual indicates for that this code, I25.84, is unacceptable as a primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met. Specifically, this claim has been billed with diagnosis code I25.84, which is a "code first" diagnosis. This means that the underlying condition must be sequenced first and I25.84 is an inappropriate primary diagnosis. Therefore, we decided that the Plan does not have to pay for observation care (99220 and 99217) provided on April 2, 2020 through April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture and an upper partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
You exhausted your benefit frequency limit, because you had dentures provided on September 6, 2016. Your 
EOC states that dentures are covered one (1) per arch every five (5) years, including a full denture, partial 
denture, or immediate denture and are not applied to the combined preventive and comprehensive maximum 
plan coverage amount. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture 
and an upper partial denture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on January 10, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the non-urgent services are not authorized because the provider is a non-network 
provider with the member's health plan, and another non-network provider with the member's health plan 
referred the member for non-covered screening services. The Plan states the member self-directed. The Plan 
states the member's network primary care physician (PCP) did not refer for services. The Plan states they 
require utilization of network providers when possible and available, and requires authorization for certain 
services. The Plan states there is no necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 has network providers 
available who can provide 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 services provided to the enrollee on January 
10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of home oxygen supplementation. 
 
You asked the Plan to pre-approve the home oxygen. You say that this is necessary. The Plan denied your 
request. The Plan says the enrollee's oxygen concentration is normal on room air. There is no rationale given 
for the need for oxygen in this case. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 home oxygen. Our reviewer says 
that the documentation does not support the need for oxygen supplementation. Our physician reviewer found 
the records show an arterial blood gas with a pO2 of 98, which is normal and does not meet criteria. There are 
no other oxygenation data that meet medical need criteria.  Home supplemental oxygen is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home oxygen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of home oxygen supplementation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist braces purchased on February 27, 2020 from a non-
Medicare provider. 
 
You asked the Plan to pay for wrist braces. You say that you lost your wrist braces while traveling and when 
you called your doctor you were told to order them from this non-Medicare provider. The Plan denied your 
request. The Plan says the provider is not a certified Medicare 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Review of the file show that you purchased wrist braces on February 27, 2020 from a non-Medicare provider. 
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. 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. 
Furthermore, Medicare does not pay for services from providers who are not Medicare certified. Therefore, we 
decided that the Plan does not have to pay for wrist braces purchased on February 27, 2020 from a non-
Medicare provider.