Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) services. 
 
You asked the Plan to pre-approve HBOT services. You say that the enrollee has a cauliflower ear on the right 
which has been a problem for the past two years. You say that the enrollee has had several surgical procedures 
and pathology showed chronic chondritis. You say that review of the literature yielded a case report of a similar 
patient who healed with conventional therapy consisting of surgery with antimicrobials and adjunctive HBOT. 
You say that the risk to benefit of a short trial of HBOT is favorable since failure to eradicate the process could 
lead to the need for a complete auriculectomy and reconstruction. The Plan denied your request. The Plan says 
the requested oxygen therapy is not covered to treat a chronic infection of the ear. The Plan says that there is 
not enough medical data to show that this treatment would be safe and effective. 
 
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 HBOT services. Our reviewer says that 
HBOT services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the main therapy for cauliflower ear is evacuating the hematoma, and for microtia cases, it is to save the 
compromise flap. The administration of hyperbaric oxygen therapy only adds to the presentation of therapeutic 
success and prevents complications. The review has determined that the enrollee does not have a covered 
indication for HBOT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT Scan provided on August 12, 2022. 
 
You asked the Plan to pay for CT Scan. You say that you are requesting reconsideration. 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 CT Scan provided on 
August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care center visit provided on 
October 06, 2022. 
 
You asked the Plan to waive the copayment for an urgent care center visit. You say that you should not be 
responsible to pay this. 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 $25 
copayment for urgent care. 
 
You have been asked to pay a $25 copayment for an urgent care center visit. This item/service falls within the 
urgent care 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 urgent care center visit 
provided on October 06, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 24, 2022, to 
August 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 24, 2022, to August 
22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on January 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available who could have provided 
these 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 physician services provided on January 4, 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 physician services provided on May 23, 2022. 
 
You asked the Plan to pay for physician services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the rendered physicians have opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
services provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee was located in a nursing home at 
the time services were rendered and the Lab must see all patients who need care. 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 laboratory services 
provided on June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 7, 2022, to 
April 13, 2022, 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 DRG 
871 was supported in the records. The Plan denied your request. The Plan says it was appropriate to revise the 
DRG from 871 to 391. 
 
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 a DRG of 871. 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 criteria for coverage have not been met. Our physician reviewer found the patient was initially 
monitored in the step-down unit due to intermittent hypotension, which would not be unusual in an individual 
having just received dialysis. She did not require intensive care unit (ICU) level of care and did not exhibit 
evidence of life-threatening organ dysfunction related to a dysregulated host response to infection. This patient 
was not described as "toxic-appearing." The patient did not exhibit persistent hypotension or hemodynamic 
instability. The total bilirubin, lactic acid and platelet count were within the normal ranges, and her mental 
status and respiratory status were intact. Sepsis is a life-threatening syndrome usually caused by bacterial 
infection. Sepsis is a response of the body's immune system that results in organ dysfunction or failure. The 
systemic inflammatory response syndrome (SIRS) criteria were recently replaced by the quick Sequential 
Organ Failure Assessment (qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in 
patients with suspected or documented infection. The qSOFA score includes a respiratory rate of 22 
breaths/minute or more, systolic blood pressure of 100 mm Hg or less, and altered level of consciousness. 
There was no clinical or laboratory evidence of sepsis. The review has determined that the documentation did 
not support DRG 871.  
 
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 April 7, 2022, to April 13, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that this service is necessary, and you need 
the Plan's help to pay for it. The Plan denied your request. The Plan says that this service is not covered under 
your benefits. 
 
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 denied coverage stating that this service is not covered 
under your medical or dental benefits. The Plans Evidence of Coverage indicates that covered dental services 
are included in the Schedule of Benefits. The Plan failed to forward the Schedule of Benefits. Without this 
information we are unable to verify the Plans denial rationale. Therefore, we decided that the Plan has to pre-
approve surgical placement of implant body: endosteal implant (D6010).  
 
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 pay for nursing facility care provided on September 21, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on September 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on August 29, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that the services provided are medical 
necessity. 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 outpatient mental health 
provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on August 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were advised that the provider was an in-
network provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the comprehensive periodontal evaluation is not covered by the Plan. 
 
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 pay for a 
comprehensive periodontal evaluation (D0180) provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to return to 
prior level of function. The Plan denied your request. The Plan says that that the coverage criteria has not been 
met. 
 
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 complex functional deficits and active 
medical issues. The evaluating therapists recommend ongoing therapy in an IRF setting, thus 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 
acute 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the non-invasive ventilator that was ordered 
is medically necessary. The Plan denied your request. The Plan says the requested device is being used in the 
bi-level positive airway pressure (BiPAP) mode rather than being used as a home ventilator. The Plan also says 
the ventilator settings ordered for the home mechanical ventilator could alternatively be provided by a BiPAP 
device with average volume assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient has severe obesity and obstructive sleep apnea (OSA) and has apparently been on bi-level positive airway pressure (BiPAP) at home for the past 5-6 years.  There is no diagnosis of 
COPD, thoracic restrictive disease, or neuromuscular disease.  A diagnosis of obesity-hypoventilation 
syndrome is listed, but there is no arterial blood gas (ABG) done while stable documenting chronic carbon 
dioxide (CO2) retention.  Overnight oximetry did not show hypoxemia while sleeping on BiPAP and oxygen, 
and capnography did not show substantial sustained increases in CO2.  The current BiPAP setting are not 
provided, there is no compliance data, and there is no device download to assess the effectiveness in the 
treatment of the OSA, to see if adjustments in pressure are warranted. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilation (NIV) 
therapy, the enrollee is at high risk for hospital readmission and potentially life-threatening exacerbations. The 
Plan denied your request. The Plan says there is no evidence that the requested mechanical ventilator is 
indicated. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient has a diagnosis of chronic obstructive pulmonary disease (COPD), although 
results of pulmonary function tests are not provided.  There is also severe obesity with obstructive sleep apnea (OSA).  Repeated arterial blood gasses (ABGs) as inpatient are consistent with chronic carbon dioxide (CO2) 
retention.  This patient may benefit from bi-level positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) and a backup rate during sleep as an outpatient.  There is no documentation 
that this has been tried and failed as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation provided on August 24, 2022. 
 
You asked the Plan to pay more for the dental service. You say that the provider told you they took your 
insurance. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a limited oral evaluation provided on August 
24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lap belt (K0108) for the approved power wheelchair. 
 
You asked the Plan to pre-approve a lap belt (K0108). You say that the requested lap belt is medically 
necessary. The Plan denied your request. The Plan says you have been approved for the requested power 
wheelchair which already includes a lap belt. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 The rules also say that each power wheelchair code is required to include a lap belt or safety belt. This means 
that the approved power wheelchair already includes a lap belt that serves the same purpose as the lap belt you 
are requesting. Therefore, we decided that the Plan does not have to pre-approve a lap belt (K0108) for the 
approved power wheelchair.