Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network, outpatient diagnostic 
magnetic resonance imaging (MRI) scan of the spine provided on June 02, 2022. 
 
You asked the Plan to waive the copayment for an in-network, outpatient diagnostic magnetic resonance 
imaging (MRI) scan of the spine. You say that do not understand, this was required for your diagnosis and 
surgery. You were never informed that you would have to pay anything. 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 $165 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $165 copayment for an in-network, outpatient diagnostic magnetic resonance 
imaging (MRI) scan of the spine. This item/service 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 in-
network, outpatient diagnostic magnetic resonance imaging (MRI) scan of the spine provided on June 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physical and occupational 
therapy with the goal of returning home and resuming their prior level of function. The Plan denied your 
request. The Plan says criteria for admission to the IRF have 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 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you received a referral from 
your primary care physician to have a regular eye exam from the treating provider. You also say that nothing 
special was done as far as you know. The Plan denied your request. The Plan says the refraction is not a 
covered benefit since it was performed with a medical diagnosis. 
 
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 when the refraction is performed during a routine eye exam. 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnoses of Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, 
right eye, Age-related nuclear cataract, bilateral, Benign neoplasm of left choroid, and Serous detachment of 
retinal pigment epithelium, right eye. You did not receive a routine eye exam at this visit. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for bone mass measurement provided on 
September 8, 2022. 
 
You asked the Plan to waive the coinsurance for bone mass measurement. You say that you disagree with the 
coinsurance. 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 40% 
coinsurance for bone mass measurement.  
 
You have been asked to pay a 40% coinsurance for bone mass measurement. The total allowed amount for the 
bone mass measurement $42.59. the amount you are being asked to pay is $17.04 ($42.59 x 40% = $17.04). 
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 bone mass measurement provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit services provided on August 
29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit services. You say that authorization is not needed 
for the services provided. The Plan denied your request. The Plan says there is no authorization on file for the 
services rendered. 
 
 
 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 a domiciliary or rest home visit services provided 
on August 29, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parental drugs (D9610). 
 
You asked the Plan to pre-approve therapeutic parental drugs. You say that this injection is medically 
necessary. The Plan denied your request. The Plan says not enough information was given to prove medical 
necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of therapeutic parental drugs have been 
met. Medical records were not provided to show the name of the injection being requested. Therefore, we 
decided that the Plan does not have to pre-approve therapeutic parental drugs (D9610).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would not receive the daily physician 
monitoring and intensive physical therapy at a lower-level rehab setting and would be at high risk for 
readmission. The Plan denied your request. The Plan says criteria for admission to the IRF have 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 not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the clinical documentation does not show any complex functional impairments 
or acute medical issues. The enrollee would not be expected to require continued inpatient hospitalization with 
an interdisciplinary approach to rehabilitation. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on October 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were given the wrong information as to 
what providers are in-network. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on October 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on July 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF visit. You say that the reports attached support the services provided. The 
Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 a skilled nursing facility (SNF) visit provided on 
July 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) on July 8, 2022. 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says that the service is not a covered benefit. 
 
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. the plans denial reason is not correct, and they offered no other rationale or 
evidence. Therefore, we decided that the Plan has to pay for a continuous glucose monitor (CGM) on July 8, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on January 17, 2022, 
to January 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that sepsis was 
documented to be present on admission. The Plan denied your request. The Plan says there is no clinical 
evidence consistent with sepsis. 
 
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 diagnosis code A41.89, defined as other specified 
sepsis. 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 services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the emergency room with cough, 
congestion, and lethargy. She tested positive for Covid-19. In this case, there was no clinical or laboratory 
evidence of sepsis. The review has determined that the documentation did not support the diagnosis code.  
 
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 provided on January 17, 2022, to January 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast surgery, to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve breast surgery. You say that this service is medically necessary. The Plan 
denied your request. The Plan says they have Plastic Surgery Specialists in network that can you with a 
treatment plan. 
 
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 
breast surgery, to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was inpatient on this date of 
service and the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 26, 2022. 
 
You asked the Plan to pay for ambulance services. You say that emergency transport is not hospice related. The 
Plan denied your request. The Plan says Original Medicare is responsible for this payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 15, 2021, to 
April 29, 2021, 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 the 
documentation supports the diagnosis. The Plan denied your request. The Plan says there was insufficient 
evidence to validate the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code L89.153, defined as healing pressure ulcer of 
the sacral region, stage 3. 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 physician reviewer found the enrollee presented with lower 
extremity pain and weakness. He was found to have a sacral wound that had a scant amount of serosanguineous 
drainage with no odor. The peri-wound skin moisture was normal with normal color. The peri-wound skin 
exhibited a callus, rash, and scarring. A stage 3 pressure injury is described as full-thickness skin loss, in which 
adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present; 
slough or eschar may be visible; the depth of tissue damage varies by anatomic location; and areas of 
significant adiposity can develop deep wounds. In this case, there was no evidence of clinical symptoms or 
findings on physical exam consistent with a diagnosis of a stage III pressure ulcer. In addition, there was no 
documentation of visible subcutaneous fat, no slough, and no documentation of undermining or tunneling. The 
review has determined that the documentation did not support the diagnosis code.  
 
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 provided on April 15, 2021, to April 29, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on September 7, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with the copayment. 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 $350 
copayment for outpatient diagnostic tests/CT scan.  
 
You have been asked to pay a $350 copayment for CT scan. This item/service falls within the outpatient 
diagnostic tests/CT scan 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 a computed 
tomography (CT) scan provided on September 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency 
transport, level 1 provided on July 21, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that emergent medical service transports should 
not be considered as part of the skilled nursing facility or hospital inpatient payment. The Plan denied your 
request. The Plan says based on the information received the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized diagnostic 
or therapeutic services not available at the facility where the patient is an inpatient. 
 
 
 
 The enrollee was a hospital inpatient at the time of service and was transported to a separate facility for testing 
which means this ambulance service is included in the inpatient payment and is not separately paid by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance service, advanced life support, emergency transport, level 1 provided on July 21, 2022.