Persius/hicric huggingface dataset:
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 the enrollee requires inpatient acute rehabilitation in 
effort to facilitate increased independence and return home and to her community with improved quality of life. 
The Plan denied your request. The Plan says the enrollee does not meet IRF criteria, is not medically necessary, 
and a lower level of care might be appropriate. Skilled nursing level of care was offered. 
 
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 the enrollee has a past medical history including hypertension, fibromyalgia, and 
end stage renal disease and is living at home with weakness and frequent falls. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional computed tomography (CT) services received on 
July 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services were performed once. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
There is no evidence that multiple imaging studies were done on this date of service. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for additional computed tomography (CT) services received on July 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of in-home support services. 
 
You asked the Plan to pre-approve additional hours of in-home support services. You say that you are sick and 
cannot do anything by yourself. You also say that the In-Home Support Services being provided are helping 
you with cleaning the house and other services you cannot do any longer due to pain. The Plan denied your 
request. The Plan says additional hours are not covered under the Plan's supplemental In-Home Support 
Services benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional hours of in-home support services have not been met. Though the Plan does not offer 
coverage for custodial care services, the Plan offers up to 30 hours per year of In-Home Support Services. The 
record shows that the Plan confirmed with the provider that you have 2.6 hours left that are included in the 
benefit. Additional hours are not covered. Therefore, we decided that the Plan does not have to pre-approve 
additional hours of in-home support services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you would prefer the Freestyle Lite 
test strips because the other strips provide inaccurate readings. The Plan denied your request. The Plan says you 
do not meet prior authorization criteria. Your provider did not provide a supporting statement documenting that 
you tried the plans preferred diabetic testing supplies or that the preferred diabetic testing supplies would be 
less effective than the preferred alternatives. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on September 01, 
2021, to September 14, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you believe that since you 
were under hospital care the entire time you should have a $0 co-pay. The Plan denied your request. The Plan 
says the cost sharing you are being charged is correct. 
 
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 $390 
copayment for per day, days 1 to 5 for inpatient hospital stay. $0 copayment per day, days 6 to 90. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day 
before you are discharged is your last inpatient day. There were 14 days, for days 1 to 5 the copayment is $390. 
$390 x 5 = $1,950. Therefore, results in the total cost sharing among of $1,950.  
 
 
 You have been asked to pay a $390 copayment for each day for days 1 to 5 of inpatient hospital stay. Inpatient 
hospital stay falls within the Inpatient hospital 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 inpatient hospital stay on September 01, 2021, to September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 23 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional trips. You say that you are still experiencing a lot of pain in your 
knee. You also say that you are not able to drive as a result. The Plan denied your request. The Plan says 
additional trips beyond the 60 one-way trips per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way 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 23 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional therapy 
and have no access to other transportation. The Plan denied your request. The Plan says as of July 19, 2022, 
you have used fifty-nine (59) of the allowed sixty (60) trips. The Plan also says an additional eighteen (18) trips 
would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way 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 additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the flex-walk system (K3 level foot micro-processing). 
 
You asked the Plan to pay for the flex-walk system. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a flex-walk system is covered for beneficiaries whose 
functional level is 3 or 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 pay for the flex-walk system. Our reviewer says that 
the documentation does support that the requested flex walk system is medically reasonable and necessary. Our 
physician reviewer found you have a history of right below knee amputation and are using a K3 level 
prosthesis which is ill fitting. Clinical documentation by provider clearly shows that you are a K3 level 
ambulator being able to negotiate various terrains at varying cadence. The documentation also supports that 
you would be able to tolerate increased activity with a flex walking system. Therefore, you meet criteria for the 
requested flex-walk system. 
 
 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 flex-walk system have been met. Therefore, we decided that the Plan has to 
pay for the flex-walk system (K3 level foot micro-processing).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Dupixent.  
 
  Benefits for Dupixent 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve denture sectioning. You say that this service should be covered. The Plan 
denied your request. The Plan says fixed partial denture sectioning (D9120) is not covered by your routine 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 fixed 
partial denture sectioning (D9120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF. You say that you need SNF care. The Plan denied your request. The 
Plan says rules for SNF care have 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing 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 SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional trips. You say that you need additional trips. The Plan denied 
your request. The Plan says additional trips beyond the allowed trips per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way 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 36 additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says based on the information received you do not need intensive team 
treatment or frequent physician evaluations. Your care can be provided in a different setting. 
 
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 you were admitted for occlusion of lower extremity bypass graft and had a below 
the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. While 
you have a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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 the IRF admission and services.
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 the enrollee will benefit from IRF in a way that 
cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the denial of 
authorization for IRF care is correct. 
 
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 the enrollee is not medically ready, needs acute medical care, and does not need rehabilitation physician supervision 3 times per week. At the current functional level, the enrollee will not 
tolerate 3 hours per day, 5 days per week of intensive rehabilitation therapies. While the enrollee may benefit 
from physical and/or occupational therapy, the enrollee's rehabilitation needs will need to be reassessed when 
medically stable and showing progress in 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the occupational therapy (OT) visit 
provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for the OT visit. The Plan denied your request. The Plan says the 
copayment was applied 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 $20 
copayment for each in-network Medicare-covered occupational therapy visit.  
 
You have been asked to pay $20 for the OT visit. The OT visit falls within the Outpatient Rehabilitation 
Services 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 an occupational therapy 
(OT) visit provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service February 8, 
2022. 
 You asked the Plan to pay for procedure code 36556. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says payment for code 36556 is bundled 
into payment for code 93503. 
 
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 code 36556 
is a column II code to column I code 93503. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36556 billed for date of service February 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care services you received on May 24, 2022. 
 
You asked the Plan to pay for the routine foot care services. You say that this service was covered last year. 
The Plan denied your request. The Plan says routine foot care is no longer a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care services have not been met. Therefore, we decided that the Plan does not have to pay for 
routine foot care services you received on May 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on March 23, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you don't believe you should have 
to pay for this because this test had nothing to do with why you were at the doctor.  You believe this test was 
unnecessary because there is nothing wrong with your thyroid. The Plan denied your request. The Plan says 
you were charged this copayment correctly.  The Plan says that because the allowed amount for this service 
($121.46) is less than your copayment obligation, 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 $125 
copayment for radiological diagnostic services (not including x-rays).  
 
You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the radiological 
diagnostic services (not including x-rays) benefit category. This cost sharing applies regardless of the reason 
for the test. 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 ultrasound you had on March 23, 2022.