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

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered on April 23, 2021, to 
April 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of primary diagnosis A41.9 and 
secondary diagnosis R65.20. 
 
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 primary diagnosis A41.9 (sepsis unspecified 
organism) and secondary diagnosis R65.20 (severe sepsis without septic shock). 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 these services. Our reviewer says that the submitted records do not 
support the billing of primary diagnosis A41.9 and secondary diagnosis R65.20. Our physician reviewer found 
the enrollee presented to the emergency department with complaints of dark colored and reduced urine. 
Discharge diagnoses were consistent with documentation throughout the record, which were noted as 
hematuria, lactic acidosis, severe sepsis present on admission secondary to urinary tract infection, and acute 
septic encephalopathy on top of severe dementia. While later progress notes stated that acute septic 
encephalopathy was present on top of dementia, the documentation was unclear. Review of the documentation 
received was unclear and incomplete to reflect a significant alteration in mental status, hemodynamic 
instability, hypoxemia, or abnormal serum platelet, total bilirubin, or creatinine levels present during this 
admission to substantiate a life-threatening organ dysfunction due to sepsis.  
 
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 services rendered on April 23, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve oxygen concentrator. You say that you need oxygen supplies and cannot 
wait for an appointment. The Plan denied your request. The Plan says the denial of authorization for this device 
is correct, because your treating provider did not fill out and submit a certificate of medical necessity. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 oxygen concentrator. Our reviewer says 
that you do not meet the Medicare criteria for the requested oxygen concentrator. Our physician reviewer found 
the only documented measurement is from January 18, 2022, when your blood oxygen was 91%. There is also 
no provider order for oxygen. 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2781, V2100, V2025) purchased on 
September 28, 2021. 
 You asked the Plan to pay for the eyeglasses. You say that you tried to have these filled in network, but your 
in-network provider was unable to provide you with eyeglasses. The Plan denied your request. The Plan says 
the provider in this case is not part of the Plan's specified optical network. Out-of-network eyewear is not 
covered by your benefit. 
 
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 these services up to $200 per year when received from an in-network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified optical 
network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2781, V2100, V2025) 
purchased on September 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services. The documentation does not support that it is medically reasonable and necessary to provide skilled 
nursing or skilled therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 14, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 63081: 
 
Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of 
spinal cord and/or nerve root(s); cervical, single segment 
 
CPT 20931: 
 
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
 
 CPT 20937: 
 
Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial 
incision) (List separately in addition to code for primary procedure) 
 
CPT 22220: 
 
Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical 
 
CPT 22554: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); cervical below C2 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found a review of the operative report does 
not show support for each of the denied codes in dispute. More documentation would be needed for each code. 
They should not be approved as not enough description is included in the operative note. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that you found this provider and would like 
to refer the enrollee to them. The Plan denied your request. The Plan says a list of in-network providers was 
given to the enrollee that provide the same service. 
 
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 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home PT/INR monitoring device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the home PT/INR monitoring device. You say that you are the only facility 
which provides these specific services. You say the enrollee has been using your services with no problems 
since 2016. The Plan denied your request. The Plan says the provider is out-of-network 
 
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 
home PT/INR monitoring device to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyewear to be provided by the requested out-of-network 
provider. 
 
You asked the Plan to pre-approve eyewear to be provided by the requested out-of-network provider. You say 
that that the online providers that are contracted with the Plan are too expensive. The Plan denied your request. 
The Plan says you need to receive your care with doctors who are contracted with your Plan. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine eyewear benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services when provided by the Plans vision network vendor. 
 We looked at the file and the Plan's rules. The file shows that the requested provider is not part of the Plans 
vision network vendor. Based on this information, we decided that the Plan's rules for coverage of eyewear 
have not been met. Therefore, we decided that the Plan does not have to pre-approve eyewear to be provided by 
the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays of the chest and a computed 
tomography (CT) scan of the abdomen and pelvis provided on October 26, 2021. 
 
You asked the Plan to waive the copayments for the X-rays and CT scan. You say that you are unable to afford 
the bill at this time. 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 $35 
copayment per day, per provider, for X-rays. 
 
Your contract with the Plan clearly says that you must pay a $150 copayment per day, per provider, for 
diagnostic radiology services, including CT scans. You have been asked to pay a $35 copayment for the X-rays and a $150 copayment for the CT scan. The X-
rays and CT scan 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 copayments for X-rays of the chest and a computed 
tomography (CT) scan of the abdomen and pelvis provided on October 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
20, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to urgent care due 
to a fall. You also say that an x-ray was not taken. 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 $40 
copayment for an urgent care center visit.  
 
  
The records show you were seen at the urgent care center. You have been asked to pay a $40 copayment for an 
urgent care visit. An urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound and laboratory services provided on June 30, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound and the laboratory services. You say that the hospital is in-
network, and you should be refunded. You say you cannot afford to pay this bill. 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. 
Therefore, we decided that the Plan does not have to pay for the ultrasound and laboratory services provided on 
June 30, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve a Dexcom device. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors 
and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
continuous glucose monitor (K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee, so 
you are requesting payment. The Plan denied your request. The Plan says the referring and the rendering 
providers are both non-participating providers with the Plan. There was no prior authorization for the service, 
and the service provided was not urgent or emergent care. 
 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 laboratory services provided on September 23, 
2021, by an out-of-network (OON) 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 does not meet 
criteria. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that he would meet criteria for admission to an acute inpatient 
rehabilitation facility. The enrollee can continue to receive care at a lower level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the mandibular partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) 
provided September 15, 2021. 
 
You asked the Plan to provide additional payment for the lower partial denture. You say that you told your 
dentist you had a $3,000 cap. The dentist went over that amount and you should not be responsible for the cost. 
The Plan denied your request. The Plan says your remaining dental allowance was applied to the claim, and 
you are responsible for the remaining cost. 
 
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. The Plan covers the lower 
partial denture up to the $3,000 annual dental maximum.  
 We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
service you had $540 remaining in your annual dental maximum. This amount was applied to your lower 
partial denture. Therefore, we decided that the Plan does not have to provide additional payment for the 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214) provided September 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the Plan's limit of 
transportation rides is not enough. You need transportation for future appointments. The Plan denied your 
request. The Plan says your benefit only allows 24 trips for this service. You have exceeded your benefit limit. 
 
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 a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips (A0120).