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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 11, 2021, to 
May 16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation submitted supports the billed diagnosis code G93.41. The Plan denied your request. The Plan 
says the documentation does not support the diagnosis code 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 diagnosis code, G93.41, defined as Metabolic 
encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the diagnosis 
code G93.41, defined as Metabolic encephalopathy. Our physician reviewer found that the review indicates that 
the enrollee was a then, 74-year-old female who presented to the facility on May 11, 2021, with complaints of 
weakness and falls at home. The past medical history included acid reflux, chronic hypoxemic respiratory 
failure, diabetes mellitus type 2, and rheumatoid arthritis. The patient was admitted to the cardiac stepdown 
unit and treated for congestive heart failure exacerbation, atrial fibrillation, and a urinary tract infection. 
 
Per Medscape Internal Medicine, Acute toxic-metabolic encephalopathy (TME), which encompasses delirium 
and the acute confusion state, is an acute condition of global cerebral dysfunction in the absence of primary 
structural brain disease. In this case, while the documentation indicated a diagnosis of metabolic 
encephalopathy, the clinical evidence did not support the condition. The review has determined that the 
documentation provided did not support the originally billed diagnosis of G93.41, defined as metabolic 
encephalopathy. 
 
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 on May 11, 2021, to May 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring provided on May 31, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring. The Plan denied your request. 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 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 remote physiologic monitoring provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D7921, D7950, D7953) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 
dental services (D7921, D7950, D7953)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 documentation shows that the enrollee has active comorbidities but there are 
no complex functional deficits specified thus the enrollee would not be expected to require intense therapy or 
interdisciplinary team management of rehabilitation in an IRF setting. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the records attached support the services. The Plan 
denied your request. The Plan says there is no prior authorization on file for the services. 
 
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 an office visit provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine services provided from March 7, 2022, 
through May 15, 2022. 
 
You asked the Plan to pay for the shingles vaccine services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this vaccine is not covered under the 
enrollee's medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine services 
provided from March 7, 2022, through May 15, 2022.  
 
Benefits for the shingles vaccine services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided on July 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing services. You say that the provided documents support the 
services. The Plan denied your request. The Plan says there is no authorization on file from the primary care 
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 genetic testing services provided on July 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a liver biopsy provided on July 19, 2022. 
 
You asked the Plan to waive the copayment for a liver biopsy. You say that you would like this waived as it 
will cause a hardship. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for a liver biopsy. This item/service falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a liver biopsy provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the new patient anesthesia consultation provided by a nurse practitioner 
(NP) on June 24, 2022. 
 
You asked the Plan to pay for the anesthesia visit. You say that the new patient visit should be payable as the 
enrollee has not been seen by an anesthesia provider in the past 3 years. The Plan denied your request. The Plan 
says that there is a prior established patient visit billed within the physician group with another NP in August 
2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The documentation provided does not support that the NP involved in the 
August 2020 visit was working under an anesthesia physician. The Plan did not attempt to obtain records for 
the August 2020 visit to determine this. The claim for this visit was billed with the primary diagnosis code 
S09.93XD, defined as Unspecified injury of face, subsequent encounter. This supports that the enrollee was 
seen after initial consultation regarding a facial injury, which would not likely be related to an anesthesia 
service. Without clear evidence to show the NPs at issue were working under the same specialty, we find that 
the denial of the new patient visit is not substantiated. Therefore, we decided that the Plan has to pay for the 
new patient anesthesia consultation provided by a nurse practitioner (NP) on June 24, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced K3 prosthetic foot. 
 
You asked the Plan to pre-approve an advanced K3 prosthetic foot. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence that the 
enrollee is a K3 ambulator or that a K3 foot is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an advanced K3 prosthetic foot. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a level 3 ambulator has the ability or potential for ambulation with variable 
cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and 
may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple 
locomotion. In this case, the documentation doesn't support that the member is a functional K3 ambulator.d The 
requested advanced foot is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced K3 prosthetic foot have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an advanced K3 prosthetic foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 11, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at a Tier 2 
ambulatory surgical center.  
 
You have been asked to pay a $400 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided to you at a Tier 2 ambulatory surgical 
center 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 outpatient surgery provided 
on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2740) 
 
You asked the Plan to pre-approve the dental crown. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 a 
dental crown (D2740)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrodesis procedure provided on April 
26, 2022. 
 
You asked the Plan to waive the copayment for an arthrodesis procedure. You say that you do not feel this is 
the correct copayment. You would like it reduced or waived. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $390 copayment for an arthrodesis procedure. This item/service falls within the 
outpatient hospital observation 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 arthrodesis procedure provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided on May 4, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that per Medicare guidelines coding 
standards were not met. The Plan further upheld this decision due to the provider's failure to provide the 
requested additional information/medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment stating that the provider failed to 
provide the requested additional information. However, the documentation confirms that the first request for 
medical records was made on October 25, 2022. The Plan sent a follow-up request and then ultimately denied 
the claim on October 28, 2022. Three days to provide medical records does not constitute a reasonable and 
diligent effort to gather medical records to support the Plans decision to not pay for the services rendered. 
Therefore, we decided that the Plan has to pay for the subsequent hospital care (99232) provided on May 4, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on June 30, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Specialist office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
Specialist office visits benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist 
office visit provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system and supplies provided 
from April 23, 2022, to April 24, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that these services 
were medically necessary. The Plan denied your request. The Plan says these items are not eligible for 
coverage under Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, (A4305, 
A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical 
equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items. Based 
on this information, we decided that Medicare rules for coverage of the disposable drug delivery system and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the disposable drug 
delivery system and supplies provided from April 23, 2022, to April 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on August 08, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration for the denied claim. 
You say that this appointment was scheduled 6 months ago as a post operation check-up when you had a 
different Plan and didnt think to get an authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an x-ray provided on 
August 08, 2022.