Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that you have lymphedema, Lipedema
and venous hypertension. You have compression stockings and ace bandages and needs help for circulation.
The Plan denied your request. The Plan says the records do not show that you have wounds on our legs,
therefore the request is not covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are
medically necessary. The Plan denied your request. The Plan says the compression stockings coded as A6549
are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be
appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from September 16, 2020, through September 19, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for inpatient services provided from September 16, 2020, through
September 19, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says based upon the Uniform Hospital Discharge Data Set (UHDDS) rules, the corrected DRG 690 is more accurate. The key diagnosis is N39.0 Urinary tract infection, site not specified.
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 A41.9, Sepsis, unspecified organism. 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 services with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee was a then, 81-year-old male with a history of hypertension, cerebrovascular accident (CVA), atrial fibrillation, and benign prostatic hyperplasia who was admitted with fever to 101, hemodynamic stability, oxygen saturation of 94% on room air, leukocytosis to 16.3, and pyuria. There was evidence of mild dehydration BUN 20, creatinine .89. Bicarbonate was 26. Liver function was normal. The C-reactive protein was elevated. Lactic acid was 1.2. Chest x-ray was negative. The enrollee was treated with intravenous (IV) Ceftriaxone and IV fluids. The enrollee was never hemodynamically unstable. The enrollee was converted to oral Cipro. While the enrollee had urinary tract infection with dehydration, the clinical scenario is not consistent with sepsis. The review has determined that the principal diagnosis A41.9, Sepsis, unspecified organism, was not supported by the medical records. 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 services provided from September 16, 2020, through September 19, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for a comprehensive electrophysiologic
evaluation performed on August 30, 2021.
You asked the Plan to reduce the coinsurance for the electrophysiologic evaluation. You say that you met your
maximum out of pocket expenses and were overcharged for this procedure. The Plan denied your request. The
Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for surgery or other services at an outpatient hospital or ambulatory surgical center.
The file shows that you had met $788.33 out of your $1100 maximum out-of-pocket (MOOP) expenses prior to
this procedure. Therefore, you have been asked to pay $311.67 for the electrophysiologic evaluation, which is
the remainder to meet your MOOP ($1100 maximum - $788.33 met = $311.67). The electrophysiologic
evaluation 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 reduce the coinsurance for a comprehensive electrophysiologic evaluation performed
on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 1, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you already paid $35 and should
not owe additional charges. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110
copayment for radiological diagnostic services.
You have been asked to pay the allowed amount of $40.30, which is less than the $110 copayment for an
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies
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 ultrasound provided on July
1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical supply provided on August 19, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the medical supply. You say that the service is payable through Medicare. The
Plan denied your request. The Plan says the service is payable; however, 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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for a medical supply provided on August 19, 2021, by
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay at a Skilled Nursing
Facility (SNF) provided from June 1, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for skilled nursing services. You say that the services you received
were medically necessary and you are upset you are being charged for your inpatient stay at the skilled nursing
facility. You also say you were not made aware of a copayment. The Plan denied your request. The Plan says
the cost-share was applied correctly according to your benefits.
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 $0
copayment, per day, for the first 20 days and a $184 copayment, per day, for days 21 through 100 for Skilled
Nursing Facility (SNF) Care.
You have been asked to pay a $2,208 copayment for skilled nursing services. The services at issue fall within
the Skilled Nursing Facility (SNF) Care benefit category. You received skilled nursing services from May 28,
2021, through June 29, 2021, or for a total of 32 days. For the first 20 days, you had a $0 copayment, per day.
For the remaining 12 days of your inpatient stay, you had a $184 copayment, per day ($184  12 days =
$2,208). 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 inpatient stay at a Skilled Nursing Facility
(SNF) provided from June 1, 2021, to June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 28, 2021, by an out-
of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that 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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 28, 2021,
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Repatha for the enrollee.  You asked the Plan to pre-approve Repatha. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha for the enrollee.   Benefits for Repatha 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee's needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that the enrollee was admitted to the acute care hospital for a scheduled laparoscopic surgery.
His hospital course was complicated by rectal anastomotic leak with pelvic abscess. Currently, he remains on
total parenteral nutrition and required intravenous Vancomycin. He is receiving appropriate care at the present
acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital
where he is currently receiving care. There are no services available at the LTACH that he requires that are not
available at the health care setting being offered by the health plan. Therefore, the requested LTACH services
are not medically necessary, reasonable, and appropriate for the diagnosis and condition for this 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October
12, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you were charged three
times for the same test. The Plan denied your request. The Plan says you have been charged the correct cost
sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15
copayment per provider per day for lab services.
The file shows only one charge for a pathological tissue exam on October 12, 2021. Therefore, you have been
asked to pay a $15 copayment for the laboratory services. The laboratory services fall within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on
October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-rays
(D0220, D0230), and fillings (D2392 x 2) provided from September 13, 2021, to October 5, 2021, by an out of
network dentist.
You asked the Plan to pay for the dental services. You say that this was an emergency. You also say that you
called the plan and were told you could go there. The Plan denied your request. The Plan says dental services
you receive out of network are not covered. The Plan also says there are in network providers in your area.
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, dental services you receive out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation (D0140), periapical x-rays (D0220, D0230), and fillings (D2392 x 2) provided from September 13, 2021, to October 5, 2021, by an out of network dentist.
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 these services to return to being
independent. The Plan denied your request. The Plan says that your comorbidities are stable, do not require
complex medical management, and do not require supervision by a rehabilitation physician.
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.
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spinal surgery. Your
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies provided on
September 29, 2021.
You asked the Plan to waive the coinsurance for the wound care supplies. You say that the supplies were not
useful and you did not use them all. The Plan denied your request. The Plan says the correct coinsurance was
applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for durable medical equipment (DME) items, including wound care supplies.
Item Allowed Amount 20% Coinsurance
Foam Dressing $104.40 $20.88
Conforming Bandage $22.08 $4.42
Gauze $3.12 $0.62
Total: $25.92
You have been asked to pay $25.92, which is 20% of the allowed amount for the wound care supplies. The
wound care supplies fall within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for wound care supplies provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cala Trio Therapy (wristband) (K1018).
You asked the Plan to pre-approve a Cala Trio Therapy (wristband). You say that there is not enough
information showing the safety and efficacy of this device for the enrollee's diagnosis. The Plan denied your
request. The Plan says this type of treatment is only covered if it is being placed by a physician and when it is
treating pain. Medicare would not cover this treatment for a tremor.
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 Cala Trio Therapy (wristband). Our
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our
physician reviewer found this type of treatment is only covered if it is being placed by a physician and when it
is treating pain. Medicare would not cover this treatment for a tremor.
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 Cala Trio Therapy (wristband) have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Cala Trio Therapy (wristband) (K1018).