Persius/hicric huggingface dataset:
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 enrollee meets the IRF criteria and is reasonably 
expected to participate in and benefit from 15 hours of therapy a week. You say that the enrollee requires daily 
physician oversight to actively manage medical conditions and comorbidities to optimize recovery and avoid 
re-hospitalization during intensive rehab. The Plan denied your request. The Plan says an IRF admission 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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided outside of the United States on 
April 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON cataract surgery. You say that the cataract surgery in dispute was 
needed urgently. You say that you were unable to return to the United States because of COVID. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules also say 
that, generally, services outside of the United States are not covered. 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 at issue in this case is not a network provider with the Plan. 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 OON cataract surgery. Our reviewer says that the criteria for coverage have 
not been met. Our physician reviewer found the records in this case do not document the cataract surgery was 
needed on an urgent basis due to unforeseen illness or unforeseen injury. The records document knowledge of 
the condition as early as December 25, 2021. While the records in this case document that the enrollee required 
"earliest care," they are inadequate to show the cataract surgery was medically necessary to prevent serious 
deterioration of the enrollee's health. The records in this case do not support that a reasonable person would 
believe that the enrollee's health would seriously have deteriorated if they delayed treatment until returning to 
the service area. 
 
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 OON cataract surgery have not been met.  
 
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 pay for the OON cataract surgery. Therefore, we decided that the 
Plan does not have to pay for cataract surgery provided outside of the United States on April 25, 2023, 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 you have been ready to discharge since the 14th of 
November. You say that you have called multiple times and was informed that there was no appeal pending. 
The Plan denied your request. The Plan says an IRF admission 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy provided on August 15, 2023. You asked the Plan to pay for the infrared therapy. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says this is not a covered acupuncture service. 
 
The Plan must follow Medicare rules. The rules say that the use of infrared and/or near-infrared light and/or 
heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such 
as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds 
and/or ulcers of the skin and/or subcutaneous tissues. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, infrared therapy is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay for the infrared therapy provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trim skin lesion provided on February 17, 2023. 
 
You asked the Plan to pay for trim skin lesion. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the requested service is not covered under your contract 
under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of trim 
skin lesion have not been met. Therefore, we decided that the Plan does not have to pay for trim skin lesion 
provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of lower false teeth arch (D5761) and the repair of 
false teeth (D5650) on tooth #20 provided on July 24, 2023. 
 
You asked the Plan to pay for the repair of lower false teeth arch (D5761) and the repair of false teeth (D5650) 
on tooth #20. You say that you need to have a tooth added to you existing partial denture. The Plan denied your 
request. The Plan says the services 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 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 repair 
of lower false teeth arch (D5761) and the repair of false teeth (D5650) on tooth #20 provided on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on May 21, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport.. You say that the services were 
medically necessary. The Plan denied your request. The Plan says without transport there are no payable 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
May 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and cone beam 
CT image capture with field of view of both jaws; with or without cranium (D0383) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of payment for 
services you received. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows you received a panoramic radiographic image (D0367) and a cone beam CT image capture with field of 
view of both jaws; with or without cranium (D0383) on date of service February 23, 2023. Therefore, these 
benefits were exhausted on date of service February 23, 2023. Therefore, we decided that the Plan does not 
have to pay for the panoramic radiographic image (D0330) and cone beam CT image capture with field of view 
of both jaws; with or without cranium (D0383) provided on July 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care management provided on February 26, 2022. 
 
You asked the Plan to pay for wound care management. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the claim was untimely, and the submission did not meet the exception 
criteria guidelines outlined in 42 CFR Section 424.44. 
 
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 wound care management was not filed until May 15, 2023. 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 wound care management provided on February 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services and to pay for 
self-administered drugs provided on May 9, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services and to pay for self-administered 
drugs. You say that the anesthesiologist did not successfully intubate you and caused harm to your vocal cords, 
throat, jaw and mouth and were not able to do the gallbladder removal surgery and you should not be 
financially responsible for their failed attempt. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 $325 
copayment for outpatient hospital services. 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. 
 
You have been asked to pay a $325 copayment for outpatient hospital services and to pay for self-administered 
drugs. This service falls within the outpatient hospital 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 outpatient hospital services and to pay for self-administered drugs provided on 
May 9, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methylprednisolone. 
 
You asked the Plan to pre-approve methylprednisolone. You say that the enrollee needs the medication because 
they have chronic pulmonary disease. The Plan denied your request. The Plan says that self-administered drugs 
do not fall under Medicare Part B coverage. 
 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 methylprednisolone.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you would like the claim processed at the in-network 
rate. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider 
without prior authorization. 
 
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 laboratory services provided on March 1, 
2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 30 miles of routine transportation added to 
the allowed 50 miles. 
 
You asked the Plan to pre-approve additional mileage. You say that you fell and broke your jaw and need this 
to be fixed, possible surgery to be able to eat. The Plan denied your request. The Plan says 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 up to 100 one-way 50-mile trips are covered each 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 an additional 30 miles of routine transportation added to the 
allowed 50 miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 11, 2022, to 
April 15, 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 the 
billed primary diagnosis of A41.9 (sepsis, unspecified organism) is not supported by the medical records. 
Instead, K57.20 (diverticulitis of the large intestine with perforation and abscess without bleeding) was re-
sequenced as the principal diagnosis, resulting in a lower DRG being paid. The Plan denied your request. The 
Plan says the diagnosis of A41.9 Sepsis, unspecified organism was billed correctly. 
 
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 the primary diagnosis of A41.9 (sepsis, unspecified 
organism). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our reviewer says that the primary diagnosis of A41.9 (sepsis, unspecified organism) is 
not supported by the medical record.  Our physician reviewer found the enrollee's condition met Systemic 
Inflammatory Response Syndrome (SIRS) for sepsis.  However, her condition did not meet Sequential Organ 
Failure Assessment (SOFA) criteria as established for sepsis. The enrollee does not meet the hemodynamic, 
respiratory, hepatic, or hematologic criteria for 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 inpatient hospital services provided on April 11, 2022, to April 15, 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 the posterior non-segmental instrumentation and the 
arthrodesis to be used with a Minuteman device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that the procedure is not experimental and 
investigational. The Plan denied your request. The Plan says the Minuteman device is not medically necessary. 
The Plan says the request is for the use of the device as a stand-alone procedure, not as part of the spine 
surgery.  
 
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 the Minuteman device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental, and more research is needed.  
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the posterior non-segmental instrumentation and the arthrodesis to be used with a 
Minuteman device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel this service should be covered because 
it was necessary to avoid further infection. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows you received an oral exam (D0120) on date of service March 13, 2023, and an emergency exam (D0140) 
on date of services April 18, 2023. Therefore, this benefit has been exhausted as of April 18, 2023. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care visit provided on August 3, 2023. 
 
You asked the Plan to pay for routine foot care visit. You say that you disagreed with the denial of payment for 
the enrollee's routine foot care visit with the provider. The Plan denied your request. The Plan says they cover 
routine foot care for members with diagnosis and medical or surgical treatment of injuries and diseases of the 
foot (such as hammer toe or heel spurs) and routine foot care for members with conditions affecting the legs, 
such as diabetes. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
routine foot care visit have not been met. Therefore, we decided that the Plan does not have to pay for routine 
foot care visit provided on August 3, 2023.