Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fixed bridges (D6240), and a retainer 
crown fixed bridges (D6750) provided by a participating provider. 
 
You asked the Plan to pre-approve a pontic-porcelain (fixed bridge) and a retainer crown (fixed bridge). You 
say that the doctor told you that you could get an infection. The Plan denied your request. The Plan says the 
services being requested 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 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 pre-approve a 
pontic-porcelain fixed bridges (D6240), and a retainer crown fixed bridges (D6750) provided by a participating 
provider.
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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from May 3, 2021, to June 30, 2021. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you had the 
coronavirus and were told that the copayments would be covered. 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 $30 
copayment for outpatient rehabilitation services.  
 
You received outpatient rehabilitation services from May 3, 2021, to June 30, 2021, for a total of 17 visits. 
Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 (copayment) x 17 (outpatient rehabilitation services) = $510.  
 
You have been asked to pay the total copayment amount of $510 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from May 3, 2021, to 
June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care billed with a diagnosis of sepsis, 
unspecified organism 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient care as billed was 
correct. The Plan denied your request. The Plan says the documentation does not support the services as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as 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 the inpatient hospital care 
as billed. Our reviewer says that the requested inpatient hospital care as billed with its primary diagnosis is not 
supported by the medical records. Our physician reviewer found that the documentation supported an 
admission for Acute subacute liver failure without coma. Documentation within the medical record was 
conflicting regarding the diagnosis of Sepsis Unspecified Organism. While Sepsis was documented in Progress 
Notes, other provider documentation was unclear and/or inconsistent regarding this condition. On Progress 
Notes it was documented, Sepsis likely due to UTI - "This point seems unlikely that this was a shift case as her 
urine grew mixed flora. Could be that her sepsis-like syndrome was related to significantly decompensated 
liver failure. Have stopped antibiotics at this point." The diagnosis of Sepsis was also not included on the 
Discharge Summary. The review has determined that the medical records do not support the principal diagnosis 
of A41.9 - Sepsis, unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care billed with a diagnosis of sepsis, unspecified organism
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided from January 4, 2020, 
through January 11, 2020. 
 
You asked the Plan to pay for ambulance transportation. The Plan denied your request. The Plan says the 
claims were received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ambulance transportation was not filed until July 15, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance transportation provided from January 4, 2020, 
through January 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file 
regarding the physicians intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 12, 2021, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  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 inpatient psychiatric care from 
November 12, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of November 12, 2021, forward. Our physician reviewer found 
you did not require inpatient mental health treatment beyond November 12, 2021, as you were not a danger to 
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve your condition or for the purpose of 
diagnosis. 
 
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 psychiatric care from November 12, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 
2021, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on June 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, CPT code 85060 is assigned 
a PC/TC indicator of 8. This means that no payment is recognized for code CPT 85060 furnished to hospital 
outpatients or non-hospital patients. The services were billed with an outpatient place of service (22). 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 the services (85060) provided on June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears unstable at this time but should only require short-term 
additional acute care services that can be safely administered at the current acute care facility until stable for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Therefore, LTACH services will be considered not medically necessary as 
transfer would not be clinically advantageous. Transfer may be considered when the enrollee is more stable and 
treatment has completed. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by out-of-network 
providers. 
 
You asked the Plan to pre-approve the office visits. You say that you are deteriorating very quick and need to 
have this issue resolved. The Plan denied your request. The Plan says they have in-network specialists as well 
as a tertiary facility available that can provide the services at issue in this request. Medicare rules say that plans 
can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 
pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care 
and care that cannot be provided by network providers. The requested provider in this case is not a network 
provider with the Plan. The Plan has network providers available who can provide the items/services at issue in 
this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, 
we decided that the Plan does not have to pre-approve the office visits to be provided by out-of-network 
providers.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97110, 97140) 
provided from May 11, 2021, to May 28, 2021. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that you were not made 
aware of the copayment and cannot afford it. The Plan denied your request. The Plan says the copayment 
applied correctly based on the services rendered. 
 
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 $40 
copayment for Outpatient Rehabilitation Services.  
 
 You have been asked to pay a $40 copayment for 5 days of physical therapy services (5 x $40 = $200). 
Physical therapy services fall within the Outpatient Rehabilitation Services 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 physical therapy services (97110, 97140) provided from May 11, 
2021, to May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
lumbar surgery and will need inpatient admission after surgery. The Plan denied your request. The Plan says 
there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee is approved for a lumbar surgery. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services (76700, 76856) provided on March 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound services. You say that these services were medically necessary 
based on the medical records. The Plan denied your request. The Plan says prior authorization was not obtained 
for these services rendered by an OON 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 the ultrasound services (76700, 76856) provided 
on March 29, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the livalo tablet 
 
You asked the Plan to pre-approve the livalo tablet. You say that the drug should be covered. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
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 the livalo tablet
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on May 
5, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you cannot afford to 
pay for the service. The Plan denied your request. The Plan says the copayment applied correctly based on the 
services provided. 
 
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 $275 
copayment for Ambulance services.  
 
You have been asked to pay a $275 copayment for ambulance transportation. 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 ambulance transportation provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lenses and anti-reflective coating provided on June 7, 
2021. 
  You asked the Plan to pay for the lenses and anti-reflective coating. You say that you paid $300 for your lenses 
because you did not want to wait and thought you would be reimbursed. The Plan denied your request. The 
Plan says routine vision services must be received from network providers. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision services when they are received from a plan network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the lenses and anti-reflective coating have not been met. Specifically, this provider is not a network 
provider for your routine vision services. Therefore, we decided that the Plan does not have to pay for the 
lenses and anti-reflective coating provided on June 7, 2021.  
 
Your complaint about being upset and disappointed with the Plan is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial ankle (L5968).

You asked the Plan to pre-approve a flex-walk system and a multi-axial ankle. You say that these items are medically necessary. The Plan denied your request. The Plan says these items exceed the enrollee's needs.

The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled flex-walk system or equal (L5981) is covered for beneficiaries whose functional level is 3 or above. L5968 is an additional feature and/or function that do not describe a complete prosthetic foot and may be used in combination with L5981. 

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 flex-walk system and a multi-axial ankle. Our reviewer says that the requested items would exceed the enrollee's needs. Our physician reviewer found the enrollee's hobbies and activities do not appear to require K3 level components.

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 flex-walk system and a multi-axial ankle have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial ankle (L5968).