Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 22, 
2021, to September 29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue were billed correctly. The Plan denied your request. The Plan says rules for payment at the 
original DRG have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the inpatient hospital services at issue do not meet 
criteria for payment at the DRG originally billed. Our physician reviewer found that there was no clear 
evidence of systemic infection or organ dysfunction related to a systemic infection. Therefore, the Sepsis 3 
criteria were not met, and the medical records do not support DRG 872 and principal diagnosis A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from September 22, 2021, to September 29, 2021, at the DRG 
originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have any documented skilled therapy or skilled nursing 
needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 26, 
2021, to November 23, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that these copayments are too high 
and you need them waived. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 had 6 specialist office visits, with each having 
a $40 copayment ($40 x 6 visits = $240). Therefore, we decided that the Plan does not have to waive the 
copayment for a specialist visit provided on August 26, 2021, to November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that your medical conditions are stable without 
any documentation to show that you would continue to require inpatient hospitalization during rehabilitation. 
 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on February 17, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that it wasn't necessary 
for transport to the hospital. The Plan denied your request. The Plan says the ambulance benefit is a 
transportation benefit. If you were not transported, no covered service has been provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you should not have been charged 
this $50 copay. You also say that they billed accordingly to get paid, but it was just a routine eye examination. 
The Plan denied your request. The Plan says a routine eye exam was not billed, and 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 $50 
copayment for a specialist's office visit under the Vision Care benefit category.  
 
 
 
 
  
You have been asked to pay a $50 copayment for the eye exam. This item/service falls within the Vision Care 
benefit category. The record shows that you received an eye exam with a specialist for cataracts. 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 eye exam (92004) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses received on January 31, 2022. 
 
You asked the Plan to reimburse you for eyeglasses. You say that you want the Plan to reimburse you for the 
eyeglasses. The Plan denied your request. The Plan says the service is not covered when received out-of-
network. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a Plan provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you 
for eyeglasses received on January 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you feel that this should be approved. The Plan 
denied your request. The Plan says the appeal records indicate you do not have any needs that require skilled 
nursing care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the limited documentation shows that the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the progressive lenses purchased on May 9, 
2022. 
 
You asked the Plan to waive the copayment for the progressive lenses. You say that your wife contacted the 
Plan twice and were told lenses are free. 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 $65 
copay for standard and premium progressive lenses under the Vision Care benefit category.  
 
You have been asked to pay a $65 copay for the progressive lenses. This item falls within the Vision 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 progressive lenses purchased 
on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra wide heavy-duty commode chair. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is unable to go to the bathroom on 
time. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, 
we decided that the Plan does not have to pre-approve an extra wide heavy-duty commode chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004), refraction (92015), and dilated 
macular or fundus exam (G8397) provided on June 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam, refraction, and dilated macular or fundus exam. You say that you 
have not been advised what kind of drug was used, and you would not know. The Plan denied your request. 
The Plan says the provider that performed these services is not in the Plan's network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, you received these services from an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam, refraction, and dilated 
macular or fundus exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
eye exam (92004), refraction (92015), and dilated macular or fundus exam (G8397) provided on June 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for syncope, ventricular fibrillation, and congestive heart failure. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the patient lift, electric, with seat or sling (E0635). 
 
You asked the Plan to pre-approve the electric patient lift. You say that you need an electric lift because your 
caregiver is 70 years old and has a hard time using the mechanical lift. The Plan denied your request. The Plan 
says the Plan has already provided the equipment which adequately meets the medical needs of the enrollee. 
An electric lift to accommodate the care giver does not meet medical necessary criteria. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary.  
 The file shows that you have a patient lift, hydraulic or mechanical (E0630). The patient lift, hydraulic or 
mechanical (E0630) serves the same purpose as the electric patient lift. Medicare does not cover equipment 
used for the convenience of a person caring for the patient. Therefore, we decided that the Plan does not have 
to pre-approve the patient lift, electric, with seat or sling (E0635).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear warranty (V2797) purchased on June 27, 2022. 
 
You asked the Plan to pay for the eyewear warranty. The Plan denied your request. The Plan says this claim 
processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you purchased a warranty for your eyewear, 
which is not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the eyewear warranty have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyewear warranty (V2797) purchased on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84436, 84479, 83550, 86140, 83721, 82040, 
84460) provided on July 31, 2018. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that the billed 
codes are column II codes to column I codes already billed. The column II codes are therefore not payable. 
Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that the Plan does not have to pay for lab services (84436, 84479, 83550, 86140, 83721, 
82040, 84460) provided on July 31, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test purchased on January 11, 2022. 
 
You asked the Plan to pay for an at-home COVID-19. You say that you have no record of taking this COVID-
19 test, nor do you know the name of the provider. The Plan denied your request. The Plan says there is no 
coverage for over-the-counter COVID-19 diagnostic test purchased prior to April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that they will cover up to eight over-the-counter 
COVID-19 tests each calendar month, after April 4, 2022.  
 
 
  We looked at the file and Medicare rules. The Medicare rules say that they will cover the over-the-counter 
COVID-19 tests after April 4, 2022. The record shows this over-the-counter COVID-19 test was purchased on 
January 11, 2022, which was before April 4, 2022. Based on this information, we decided that Medicare rules 
for coverage of an at-home coronavirus (COVID-19) have not been met. Therefore, we decided that the Plan 
does not have to pay for an at-home coronavirus (COVID-19) test purchased on January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no records of the enrollee trying other conservative managements. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that you have a long-standing history of low back pain with radiculopathy. Th record does not 
indicate the presence of red flag symptoms or any neurologic abnormality.  The record does not indicate that 
the enrollee has tried and failed physical therapy.  The requested service is not medically necessary and 
reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time.  The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex procedure is experimental. More research is needed to demonstrate 
the safety and efficacy of the procedure. 
 
 
  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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablet 4mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a benefit exclusion. 
 
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 Ondansetron tablet 4mg.