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's condition could get more complicated. 
The Plan denied your request. The Plan says documentation shows the enrollee has not completed their full 
hospital treatment and they cannot take part in and benefit from intense therapy. The enrollee's condition 
requires further care in the acute care hospital. 
 
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 the enrollee has multiple medical issues and would benefit from close medical 
monitoring however evaluating therapists state that the enrollee would not tolerate intense therapy thus IRF 
criteria not met. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied admission to the IRF 
with medical records. The Plan denied your request. The Plan says that the documentation does not show that 
the enrollee is able to actively participate in intensive therapy and that they do not need a doctor trained in 
rehabilitation to supervise their therapy and to see the enrollee at least three times per week. The enrollee's 
medical needs can be met at a lower-level setting such as a skilled nursing facility, home health care, or 
outpatient therapy services. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has many medical complications and would 
benefit from close medical monitoring on an inpatient basis. Evaluating therapists state that the enrollee has 
good rehabilitation potential and would benefit from intense therapy. IRF criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT), cervical spine (72125), CT 
of head/brain (70450), and 3D rendering with interpretation and reporting of computed tomography (76376) 
provided on November 17, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT), cervical spine (72125), CT 
of head/brain (70450), and 3D rendering with interpretation and reporting of computed tomography (76376) 
provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was unaware of and does not 
understand the medical plan in which she is enrolled. You say you would like to continue treating her. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that you tried to get a retro-referral from the 
enrollee's doctor. You say you were unable to obtain it because the primary care physician has not seen the 
enrollee for an appointment in several months. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 30, 2021, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment, by report (D5862) and a surgical 
placement of a mini implant (D6013). 
 
You asked the Plan to pre-approve dental services. You say that you have lost weight and you need dentures 
implanted into your jaw so that you can eat. You also say that you would like the Plan to reconsider because it 
will be beneficial to your health, and you do not want to end up in the hospital. The Plan denied your request. 
The Plan says the requested services are not covered under your benefit package. 
 
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 
precision attachment, by report (D5862) and a surgical placement of a mini implant (D6013).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on February 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the hospital staff to 
verify eligibility and to obtain the proper authorization from the enrollee's insurance company. You say the 
service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on February 4, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 60 one-way 
trips with each one-way trip not exceeding 75 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 75 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 84 miles away from your residence. The Plan only covers distances up to 75 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home Prothrombin Time/International Normalized 
Ratio (PT/INR) monitoring. 
 
You asked the Plan to pre-approve the requested services. You say that you were on Eliquis, but it was not 
working. The Plan denied your request. The Plan says the documentation does not support the need for home 
monitoring supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that home PT/INR monitoring is only covered under 
certain medical indications. 
 We looked at the file and Medicare rules. The medical records show that Coumadin (Warfarin) was started 
May 23, 2022. The services at issue are covered when you have been anticoagulated for at least 3 months. 
Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve home Prothrombin Time/International 
Normalized Ratio (PT/INR) monitoring.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient eye surgery provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you already paid a copayment for an 
eye surgery on this eye and should not need to pay again to correct scar tissue. The Plan denied your request. 
The Plan says the copayment applied was 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 $225 
copayment for each Outpatient Surgery and/or Services at an Ambulatory Surgical Center. 
 
You have been asked to pay a $225 copayment for an eye surgery. An eye surgery falls within the Outpatient 
Surgery and/or Services at an 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 eye surgery provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Saebo glove. 
 
You asked the Plan to pre-approve a Saebo glove. You say that this item is needed for spasticity in the hand. 
The Plan denied your request. The Plan says the requested item is not medically 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 a Saebo glove. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a history of a stroke. The documentation shows that you have decreased range of 
motion and function of the left upper extremity with contracture and spasticity. There is limited clinical 
information provided regarding the request for the upper extremity orthotic hand splint. It is not clear how you 
have responded to other treatment modalities, specifically therapy and injection with botulinum toxin. These 
therapies are both recognized as standard of care in the treatment of spasticity and contracture. There is also 
limited medical literature supporting the use of the requested Saebo Glove. There is one pilot feasibility study 
showing that it could be successfully used in a sample of stroke enrollees with little or no active hand 
movement. However, there is no medical literature demonstrating that it is superior to or at least as beneficial as existing and available medically appropriate treatment for your contracture and spasticity secondary to 
stroke. Therefore, you do not meet criteria for the requested item. 
 
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 Saebo glove have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Saebo glove.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visits provided April 10, 2020, to May 9, 
2020. 
 
You asked the Plan to pay for the home health visits. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
The Plan follows Medicare rules. Medicare rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be 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 home health visits. Our reviewer says 
that the services billed are not supported by the documentation. Our physician reviewer found the enrollee 
received home health visits. The documentation includes the enrollee being able to ambulate with contact guard 
assist, ability to transfer from chair to standing without assistance, ability to toilet/tub/shower transfer without 
direct assistance, and the ability to dress and wash independently, but has some fall risk. Therefore, the 
documentation does not support 3HC11. Coding of 3HA11 is more supported by the documentation provided. 
 
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 home health visits have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health visits provided April 10, 2020, to May 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310), a therapeutic parenteral drug 
(D9610), and removal of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve a consultation, a therapeutic parenteral drug, and removal of torus 
mandibularis. You say that the requested services are medically necessary. The Plan denied your request. The 
Plan says the services at issue are not covered 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 a 
consultation (D9310), a therapeutic parenteral drug (D9610), and removal of torus mandibularis (D7473 x2).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI), any joint of upper extremity 
(73221). 
 
You asked the Plan to pre-approve a MRI. You say that without the MRI your provider cannot determine 
whether the pain is coming from either the joint or neck. You say that this has been ongoing for 6 months. You 
say that you have no other options left. You also say that the pain is worsening so there must be some active 
issue. The Plan denied your request. The Plan says that the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MRI. Our reviewer says that the 
requested MRI is medically necessary. Our physician reviewer found the provided documentation indicates a 
positive Hawkins test which likely means impingement. The reviewer found that the enrollee has had a course 
of oral medications and subacromial steroid injection.  The documentation indicates the enrollee has pursued a 
physical therapy (PT) program but has not completed it. The reviewer also found that the enrollee is still 
symptomatic. Therefore, the reviewer found that the requested MRI is medically reasonable and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve a 
magnetic resonance imaging (MRI), any joint of upper extremity (73221).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 18, 2021, to 
February 10, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 640 is more appropriate in this case, with hypo-osmolality and hyponatremia (E87.1) 
sequenced as the principal diagnosis. 
 
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. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found the enrollee was admitted and treated for a urinary 
tract infection (UTI), hyponatremia and hypo-osmolality. Sepsis was listed; however, there was insufficient 
criteria met for sepsis 3 criteria requirements. Treatment of the hyponatremia improved the enrollee's altered 
mental status and there was no direct evidence of systemic infection causing organ failure or encephalopathy. 
Therefore, the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 18, 2021, to February 10, 
2021, as billed with Diagnosis Related Group (DRG) 871.