Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayments and for out-of-network (OON) 
psychotherapy services provided from September 15, 2021, to March 23, 2022. 
 
You asked the Plan to waive the deductible and copayments and for the OON psychotherapy services. You say 
that the services were medically necessary and should be covered. The Plan denied your request. The Plan says 
the correct deductible and copayments were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 30% coinsurance for each out-of-network 
(OON) therapy visit after the deductible is met. 
 
 
 Dates of Service Allowed Amount Deductible/30% Coinsurance 
September 15, 2021 $255.50 $76.65 (30%) 
October 27, 2021 $146.15 $43.85 (30%) 
December 8, 2021 $146.15 $43.85 (30%) 
February 16, 2022 $144.59 $144.59 (deductible) 
March 23, 2022 $144.59 $144.59 (deductible) 
Total:  $453.53 
 
The psychotherapy services fall within the Outpatient Mental Health Care benefit category. For dates of 
services in 2021, the deductible had already been met, therefore, you have been asked to pay a 30% 
coinsurance for each therapy visit. For dates of service in 2022, the Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the OON psychotherapy services were 
received on the 2022 dates of services. Therefore, we decided that the Plan does not have to waive the 
deductible and copayments and for out-of-network (OON) psychotherapy services provided from September 
15, 2021, to March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair a raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair. You say that the items are needed to prevent from falling. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and raised toilet seat.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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 a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is needed to get in and out of the 
tub/shower, due to safety concerns. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment 
(98941), neuromuscular reeducation (97112), and the acupuncture treatment (97810) provided from January 4, 
2022, through January 25, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services at 
issue are not payable as the provider of service is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the case file indicates that the provider of service is not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to issue reimbursement for the chiropractic manipulative 
treatment (98941), neuromuscular reeducation (97112), and the acupuncture treatment (97810) provided from 
January 4, 2022, through January 25, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
December 27, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining prior authorization for all their patients, which should also cover medical treatments. 
The Plan denied your request. The Plan says the available case documentation and medical records were 
reviewed by a Plan Medical Director, and it was determined the services were not urgent or emergent. It was 
also determined the services rendered could have been provided by a participating provider under the members 
Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 6, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the rendering provider is a non-participating provider. The Plan also 
says that the referring provider involved in these services is a non-participating provider with the Plan. The 
Plan also says that they did not authorize any services for this 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. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 laboratory services provided on August 6, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve dialysis to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 
dialysis to be provided by an out-of-network (OON) provider.
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 you have a diagnosis of type 2 diabetes, 
Parkinsons, hypertension, obesity, bilateral knee pain and leg edema. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre (CPT code K0553). 
 
You asked the Plan to pre-approve the FreeStyle Libre. You say that the FreeStyle Libre is necessary. The Plan 
denied your request. The Plan says no clinical information was provided to support the use of FreeStyle Libre. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the FreeStyle Libre (CPT 
code K0553) have been met. No chart notes and clinicals were provided to verify if you meet the Medicare 
criteria for the FreeStyle Libre. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle 
Libre (CPT code K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
January 21, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the providers rely on facility 
staff to verify eligibility and obtain authorization from the patients insurance company. The Plan denied your 
request. The Plan says the information received did not provide just cause for the services to be rendered 
without obtaining prior authorization. The services were not urgent or emergent and the services could have 
been rendered by a Plan participating 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. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic bone marrow biopsy and diagnostic bone 
marrow aspiration provided on January 4, 2022. 
 
You asked the Plan to pay for a diagnostic bone marrow biopsy and diagnostic bone marrow aspiration. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a diagnostic bone marrow biopsy and diagnostic bone marrow 
aspiration provided on January 4, 2022.
Appeal type: Transportation
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 the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
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 40 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
November 3, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining prior authorization for all their patients, which should also cover medical treatments 
for this provider. The Plan denied your request. The Plan says the available case documentation and medical 
records were reviewed by a Plan Medical Director, and it was determined the services were not urgent or 
emergent. It was also determined the services rendered could have been provided by a participating provider 
under the members Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) for all four quadrants. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. You say that you need this service. 
The Plan denied your request. The Plan says that your tooth must have noticeable bone loss or show on an x-
ray that there is a hard substance built up on the root of the tooth. Your x-rays do not show that you have these 
issues. 
 
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. The Plan covers the 
periodontal scaling and root planing when the services are medically necessary and reasonable. 
 
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 periodontal scaling and root 
planing. Our reviewer says that the periodontal scaling and root planing was medical necessary. Our physician 
reviewer found that a review of the documentation indicates the presence of pathological periodontal pockets in 
all quadrants (<4mm) and areas of bone loss. Periodontal scaling and root planing is medically reasonable and 
necessary to treat the enrollees periodontal disease 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal scaling and root planing have been met. Therefore, we decided 
that the Plan has to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) for all four quadrants.  
 
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 the inpatient hospital care provided from July 5, 2019, 
through July 9, 2019, and billed with the principal diagnosis code I82.41. 
 You asked the Plan to pay for the inpatient hospital care as billed. You say that this claim was billed with a 
valid principal diagnosis code and should not have been changed by the Plan. The Plan denied your request. 
The Plan says the documentation does not support payment for the inpatient hospital care 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 principal diagnosis code, I82.41, defined as acute 
embolism and thrombosis of left femoral vein. 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 care as billed. Our reviewer says that the documentation does not support the originally 
billed principal diagnosis code I82.41, defined as acute embolism and thrombosis of left femoral vein. Our 
physician reviewer found that the patient is a 78-year-old female who presented to the facility with a 3-day 
history of left lower extremity pain and swelling. An ultrasound was obtained which noted a left femoral deep 
vein thrombosis (DVT) with extension down into the left calf. The patient was also noted to be tachycardic and 
had oxygen saturations in the 88-91% range. The provider has indicated that the patient was only symptomatic 
in regards to her DVT; however, as noted, the patient was found to be tachycardic and hypoxic in the 
emergency department which necessitated pulmonary embolism (PE) rule out. The patient was also noted to 
have elevation of troponins. In addition, while both conditions did require diagnostic procedures at admission, 
the PE required additional work up with an echocardiogram. Furthermore, at discharge the physician listed the 
principal diagnosis as the pulmonary embolism. 
 
The review has determined that the documentation did not support the billed principal diagnosis code I82.41, 
defined as acute embolism and thrombosis of left femoral vein but did support the Plan's adjusted principal 
diagnosis code I26.99, defined as other pulmonary embolism without acute cor pulmonale.  
 
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 the inpatient hospital care provided from July 5, 2019, through July 9, 2019, and billed with the principal 
diagnosis code I82.41.