Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services in the home health setting. 
 
You asked the Plan to pre-approve skilled nursing services in the home health setting. You say that the medical 
documentation provided supports the need for the requested services. The Plan denied your request. The Plan 
says the medical necessity criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing services in the home 
health setting. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
the enrollee does not have documented skilled nursing needs. As such, the requested, ongoing, home health 
skilled nursing services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing services in the home health setting have not been met. 
Therefore, we decided that the Plan does not have to pre-approve skilled nursing services in the home health 
setting
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received on June 24, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you have had to have this service in the 
past and never paid an additional copayment for it. The Plan denied your request. The Plan says you were 
charged this copayment 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 $35 
copayment for x-rays.  
 
You have been asked to pay a $35 copayment for the TTE. Plans are permitted to charge separate cost sharing 
for diagnostic testing you receive in a physician's office. 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 transthoracic echocardiography (TTE) you received on June 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support that an 
LTACH is the most appropriate level of care. You say that you require 29 more days of IV antibiotics, 
management by ID and nephrology, physical and occupational therapy to address severe debility, and a wound 
team to manage your wound. The Plan denied your request. The Plan says the enrollee's needs can be met at an 
alternate level of care. The Plan says that the services needed do not require the level of services an LTACH 
provides. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with fever, chills, 
purulent drainage at left hip from hip infection after left hip arthroplasty. The enrollee had not failed outpatient 
treatment and was started on antibiotics with plans for an additional 29 days of IV antibiotics. The enrollee's 
vitals were stable, and Leukocytosis was improving with treatment.  
 
 
The enrollee appears to be improving with current treatment and is more stable. They require only short-term 
additional acute care hospital services that can safely be administered at the current facility. The enrollee does 
not require services at the LTACH that are not already available at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bi-level positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of COPD, but there are no pulmonary function tests to confirm and assess the severity of the
diagnosis. The enrollee has severe obesity. The enrollee was hospitalized on July 16, 2021 with acute respiratory failure and sepsis. The enrollee was apparently readmitted on August 2, 2021, but the details are unclear. As of August 30, 2021, the enrollee was apparently in a nursing facility. The enrollee is apparently on continuous positive airway pressure (CPAP) at night for obstructive sleep apnea. There is no confirmation of carbon dioxide (C02) retention while the enrollee is awake and medically stable out of the hospital. The most appropriate treatment for the enrollee would be BiPAP at night, if persistent CO2 retention is confirmed. Medicare does not cover a ventilator when used as BiPAP. Certain BiPAP devices can provide the AVAPS mode of support 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and surgical placement 
of implant body: endosteal implant (D6010) provided on June 24, 2021, and July 13, 2021. 
 
You asked the Plan to pay for the periodontal maintenance and endosteal implant. You say that you would like 
to appeal these services. The Plan denied your request. The Plan says these services are purely dental in nature. 
The Plan also says that these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910) and surgical placement of implant body: endosteal implant (D6010) provided on June 24, 2021, and 
July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a comprehensive oral evaluation (D0150), a tooth 
extraction (D7210) and a panoramic radiographic image (D0330) provided on May 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to reimburse you for a comprehensive oral evaluation, a tooth extraction, and a panoramic 
radiographic image. You say that the dental surgeon refused to take your Plan. You also say that you would 
like the Plan to reimburse you for your dental services. The Plan denied your request. The Plan says there is no 
coverage for when services are rendered by an OON provider. 
 
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.  
 
 
We looked at the file and Medicare rules. Though the Plan offers a dental benefit in excess of Medicare 
coverage, you are responsible for 100% of the cost for dental services rendered by an OON provider. 
Therefore, we decided that the Plan does not have to reimburse you for a comprehensive oral evaluation 
(D0150), a tooth extraction (D7210) and a panoramic radiographic image (D0330) provided on May 18, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), vertical bitewings 
(D0277) and prophylaxis (D1110) provided on May 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic oral evaluation, vertical bitewings, and prophylaxis. You say that you 
had these dental services done last year and this year, there was no compensation for the same procedure with 
your dentist. You also say your policy compensation changed and you want to know how it was changed. The 
Plan denied your request. The Plan says there is no coverage for when services are rendered by an OON 
provider. 
 
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, the requested items or services are not 
among those covered under this benefit. You are responsible for 100% of the cost for dental services rendered 
by an OON provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), vertical bitewings (D0277) and prophylaxis (D1110) provided on May 19, 2021, by an out-of-
network (OON) provider.  
 
Your complaint about your policy compensation is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration 
because the member is living with severe pain. The Plan denied your request. The Plan says that the records do 
not show that the member had diagnostic injections or the percentage of relief from a diagnostic injection. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 facet joint injections. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that the member has had sustained relief from these blocks. 
 
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 facet joint injections have been met. Therefore, we decided that the Plan has 
to pre-approve facet joint injections.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care billed with diagnosis codes A41.9 and 
R65.20 provided from March 30, 2020, to April 5, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the billed diagnosis codes are supported in 
the medical records submitted. The Plan denied your request. The Plan says the medical records do not support 
the diagnoses as billed. 
 
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 the diagnosis code A41.9 defined as sepsis, 
unspecified organism and diagnosis code R65.20 defined as severe sepsis without septic shock. 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 inpatient hospital care. Our reviewer says that the diagnosis 
codes are not supported in the medical records submitted. Our physician reviewer found that the enrollee was a 
then, 78-year-old male with a history significant for chronic obstructive pulmonary disease, dementia, chronic 
diastolic congestive heart failure, severe protein malnutrition, transient ischemic attack, hypertension and 
hyperlipidemia, who presents to the emergency department via emergency medical services with complaints of 
shortness of breath. Appeal Letter notes that the reported vital signs support the physician's consistent 
diagnostic statement of sepsis with tachypnea, hypotension and bradycardia, also lab values showing 
leukocytosis, elevated lactic acid, hyperchloremia and hypophosphatemia as signs of a systemic response. 
While the patient presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-
threatening organ dysfunction due to dysregulated host response to an infection, persistent hemodynamic 
instability or cognitive impairment that would be consistent with multi-system involvement due to sepsis.  
 
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 care billed with diagnosis codes A41.9 and R65.20 provided from March 30, 2020, to 
April 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve the inpatient hospital admission. The Plan denied your request. The Plan 
says this request is 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 pre-approve the inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. 
 
 
Our physician reviewer found as the enrollee was not significantly hypoxic or hemodynamically unstable and 
had chronic atrial flutter starting to be controlled at the time of admission, it was not expected that the enrollee 
would require hospital services that would likely cross 2 midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the stereoscopic x-ray (G6002) rendered by the out-of-
network (OON) provider on May 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the stereoscopic x-ray (G6002) rendered by the out-of-network (OON) provider on 
May 4, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services you had on July 27, 2021, and 
July 29, 2021. 
 
You asked the Plan to waive the copayments for the lab services. You say that these were routine labs that were 
part of a routine physical exam.  You stated that there should be no copayment. The Plan denied your request. 
The Plan says you were charged these copayments 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 $2 
copayment for lab services.  

You have been asked to pay a $2 copayment for the lab services. Your Evidence of Coverage explicitly states 
the services that are part of an annual physical.  The contract also says that other services, such as labs, are not 
included in the cost of the annual physical and separate cost sharing will apply. 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 lab services you had on July 27, 2021, and July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0651, E0667) 
provided on August 4, 2020. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for mild edema. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0651, E0667) provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received from an out-of-
network hospital on July 2, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that the doctor's office told you that if 
you went to the hospital for the lab services, there would be no copayment. The Plan denied your request. The 
Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for these 
lab services ($27.36) is less than your copayment, you are responsible for the full allowed 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 $35 
copayment for lab services at an out-of-network outpatient hospital facility.  
 
You have been asked to pay a $35 copayment for the lab services. Both the primary care provider who ordered 
the lab services and the hospital where you received them are out-of-network with the Plan.  The Plan cannot 
be held responsible for incorrect information that may have been given to you by an out-of-network provider. 
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 lab services you received from an out-of-network hospital 
on July 2, 2021.