Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that your husband had a biopsy that the doctor 
sent to this provider to be sure it was not cancerous, and you did not know that the laboratory and the physician 
were not participating providers. You say that if you had known, you would have asked for a prior 
authorization or for the doctor to send the specimen to another provider. The Plan denied your request. The 
Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 laboratory services provided on January 7, 2022.
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 5, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home. You say that the assisted living facility is responsible 
for obtaining prior authorization for all their patients, which should also cover for medical treatments provided 
by this physician. 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 
service 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 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 19, 2021, to October 26, 2021. 
 You asked the Plan to pay for the services. You say that the diagnoses are supported by the physician's 
documentation and the information contained in the patient's medical record. The Plan denied your request. The 
Plan says the DRG was updated. 
 
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 DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that the review has determined that the records did not support the use of 
diagnosis codes A41.9 (sepsis, unspecified organism) and R65.20 (severe sepsis without septic shock) in this 
case. DRG 193 SIMPLE PNEUMONIA AND PLEURISY WITH MCC is more appropriate.  
 
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 to the enrollee from October 19, 2021, to October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 7, 2021, to March 11, 2021. 
 
You asked the Plan to pay for the services. You say that you disagree with the removal of the diagnosis codes. 
The Plan denied your request. The Plan says the DRG was updated.  
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 DRG 038 (EXTRACRANIAL PROCEDURES 
WITH CC). 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 services. Our reviewer says that 
the services at issue in this case were not supported by the medical records. Our physician reviewer found that 
while the patient had a serum sodium slightly below the hospital laboratory's lower limit of normal at 133, there 
was no documentation by the treating physician of an explicit treatment plan to correct the condition. The 
documentation in the progress notes listed an etiology of pain; however, pain alone is not typically considered a 
clinical etiology of the condition. In addition, the sodium remained below the hospital laboratory's lower limit 
of normal at 134 on the day of discharge with no indication that the condition required follow-up in the 
outpatient setting. The review has determined that the records do not support the use of E87.1 (Hypo-
osmolality and hyponatremia) and N39.0 (Urinary tract infection, site not specified) in this case. The records 
support DRG 039.  
 
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 to the enrollee from March 7, 2021, to March 11, 2021.
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 19, 2022. 
 
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 for medical 
treatments provided by this physician. 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 January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment services provided on March 25, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation treatment services. You say that you were referred to this provider by 
one of the Plan doctors for radiation treatment. You also say that you would not have gone there if they did not 
think it was authorized. The Plan denied your request. The Plan says this provider is not a contracted  provider. 
The Plan also says that there are many contracted providers in the area for radiation oncology that are familiar 
with Plan benefits, including the prior authorization requirements for radiation oncology. 
 
 
 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 radiation treatment services provided on March 
25, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aorta ultrasound provided to the enrollee on 
March 17, 2022. 
 
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 payment is not allowed for this service, because it is not supported by the diagnosis billed or the 
documentation received. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that dyspnea on exertion is not a recognized clinical indication to screen for abdominal aortic aneurysm 
(AAA), as per Medicare guidelines. In particular, the Centers for Medicare & Medicaid Services (CMS) has 
authorized a once in a lifetime ultrasound screen for AAA in the instance where the patient is 65-75 years of 
age, and has smoked at least 100 cigarettes in their lifetime. Such a history was not included in the report of the ultrasound. Therefore, in this case particular case payment should be denied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an abdominal aorta ultrasound provided to the enrollee on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat lumbar epidural steroid injection. The Plan denied your request. 
The Plan says a repeat epidural steroid injection is not medically necessary and does not meet the Medicare 
LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 repeat lumbar epidural steroid 
injection. Our reviewer says that a repeat lumbar epidural steroid injection is not medically necessary. Our 
physician reviewer found that in this case, there is no documentation that the enrollee had 50% sustained 
improvement in pain for at least three (3) months. The enrollee had undergone recent interlaminar epidural 
steroid injections on March 28, 2022, and May 16, 2022. The provider recommended a third epidural steroid 
injection to be performed three to four weeks after the last injection. The review has determined that the 
requested repeat lumbar epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
 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 repeat lumbar epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection.
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 you need a safe discharge home, and need 
rehabilitation to get better. The Plan denied your request. The Plan says your needs can be met at a lower level 
of care such as a skilled nursing facility (SNF). 
 
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 you had a routine post-orthopedic injury. You are weight-bearing as tolerated. You do not have complex or intensive rehabilitation needs. There is no evidence-based support for this 
admission to acute rehabilitation for an uncomplicated orthopedic 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete dentures (D5110) provided on March 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income and cannot afford this 
bill. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 4, 2019. Therefore, 
we decided that the Plan does not have to pay for maxillary complete dentures (D5110) provided on March 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Injectafer. There is 
no indication that the enrollee has tried and failed the required drugs. Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the Plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided January 14, 2022. 
 
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 lab services are not separately payable. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 82728, 83540, 83550, 83970, 84100) provided January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage of a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM).
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 requested admission to an IRF is medically 
necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do 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 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. Medically 
necessary care can be provided in a different level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on March 30, 2021, and April 
26, 2021 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges and they would cause a financial hardship. The Plan denied your request. The Plan says the 
services denied correctly as they exceed your $1,000 dental benefit maximum. 
 
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. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on March 30, 2021, and April 26, 2021