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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 20, 2022, 
through July 22, 2022. 
 
 
  
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review indicates that the enrollee presented to the emergency department (ED) on  
July 20, 2022 and was evaluated and admitted with a diagnosis of iron deficiency anemia. The enrollee 
responded appropriately to a packed red blood cell (PRBC) infusion and was asymptomatic. The enrollee was 
hemodynamically stable, there was no evidence of active bleeding, no urgent indication for an endoscopy 
procedure, and oral Warfarin was continued. The review has determined that the record did not show that at the 
time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 20, 2022, through July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on March 28, 2023. 
 
You asked the Plan to pay for the debridement services. You say that the services were medically necessary. 
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 the debridement services 
provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular RFA (64624) provided on March 3, 2022. 
 
You asked the Plan to pay for the RFA. You say that this service was medically necessary for the enrollee's 
diagnosis.  The Plan denied your request. The Plan says this service was not medically necessary. 
 
We reviewed the Local Coverage Determination (LCD) cited by the Plan and found it was not applicable to the 
jurisdiction. 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 pay for the RFA. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that RFA is considered an experimental investigational therapy. It is the subject of ongoing clinical trials. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pay for the genicular RFA (64624) provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed rails (E0305). 
 
You asked the Plan to pre-approve the bed rails. You say that this item is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that side rails (E0305, E0310) or safety enclosures 
(E0316) are covered when they are required by the beneficiary's condition and they are an integral part of, or an 
accessory to, a covered hospital bed. 
 
We looked at the file and Medicare rules. The requested side rails are not for use on a covered hospital bed. 
Based on this information, we decided that Medicare rules for coverage of the bed rails have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bed rails (E0305).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter to go out and not be under 
stress. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a foldable scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 3) and bone replacement 
grafts for ridge preservation (D7953 x 3) 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered under the Plan's dental 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 pre-approve 
endosteal implants (D6010 x 3) and bone replacement grafts for ridge preservation (D7953 x 3)
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits x224. 
 
You asked the Plan to pre-approve home health aide visits x224. You say that you do not agree with the denial 
of the requested services.  The Plan denied your request. The Plan says the services are not medically 
necessary. There is no documentation of any skilled services being received at this time. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide service visits x224 have not been met. Specifically, we find that the services at 
issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-
approve home health aide visits x224.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you want the insurance to pay for it. The Plan denied 
your request. The Plan says the services received were not authorized. 
 
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 an office visit provided on April 27, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aspheric acrylic monofocal intraocular lens implants 
(V2799). 
 
You asked the Plan to pre-approve an aspheric acrylic monofocal intraocular lens implants (V2799). You say 
that you feel the Plan should pay partial. The Plan denied your request. The Plan says services are not covered 
under Original Medicare, unless such services are specifically listed as covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that they will only cover and pay for 
conventional IOLs during cataract surgery. Medicare rules say that the enrollee will be responsible for the 
difference in cost between a non-conventional IOL and a conventional IOL.  
 
  While the requested aspheric IOL may be appropriate, neither the Plan nor Medicare covers a non-conventional 
IOL. Since this aspheric lens is not a conventional IOL, Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an aspheric acrylic monofocal intraocular 
lens implants (V2799).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve the medication. You say that the enrollee has not responded well to steroid 
injections, Tylenol, or rest. The Plan denied your request. The Plan says the enrollee has not tried and failed 
preferred medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the enrollee has not trialed a preferred viscosupplemental treatment such as Orthovisc or Supartz 
FX. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not 
outline contraindications or reasons these medications were not considered or that the plans additional 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stationary exercise bike you purchased on January 7, 
2023. 
 
You asked the Plan to pay for the exercise bike. You say that this item is needed for recovery following knee 
surgery. You needed to exercise after surgery to prevent scar tissue from forming. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that exercise equipment is excluded from coverage 
because it is not primarily medical in nature.  The exercise bike you purchased is considered non-covered 
exercise equipment, even if you are using it following surgery. Therefore, we decided that the Plan does not 
have to pay for the stationary exercise bike you purchased on January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the intraoral 
complete series of radiographic images (D0210), the immediate upper denture (D5130), the immediate lower 
denture (D5140), an extraction (D7140) for tooth #22, #23, #24, #25, #26, and #28, and the surgical extraction 
(D7210) for tooth #5, #6, #12, #13, #14, #19, #29, and #31 provided on February 2, 2023. You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider your 
request for payment. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because dentures are a non-covered dental service; therefore, all the related services to the dentures are 
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 dentures are not among those 
covered under this benefit and any services related to a non-covered dental benefit are also excluded from 
coverage. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), the intraoral complete series of radiographic images (D0210), the immediate upper denture (D5130), 
the immediate lower denture (D5140), an extraction (D7140) for tooth #22, #23, #24, #25, #26, and #28, and 
the surgical extraction (D7210) for tooth #5, #6, #12, #13, #14, #19, #29, and #31 provided on February 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service provided on March 29, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the debridement service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network provider for certain 
covered services. The Plan contract also says out-of-network podiatry services are not covered. 
 
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 debridement service provided on March 29, 
2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
16, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $285 
copayment for outpatient surgery. 
 
You have been asked to pay a $285 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient surgery 
provided on March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 6, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 6, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from May 5, 2022, to May 6, 
2022. 
 
You asked the Plan to pay for the medical services. You say that you believe the patient's other insurer will not 
pay, so the Plan should pay this claim. The Plan denied your request. The Plan says this claim needs to be 
billed to the patient's primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted 
you and advised you of who the primary insurer is, and to submit your claim to that primary insurer. You have 
not provided evidence that this claim has been received and processed by the patients other insurance. As the 
secondary insurer, the Plan cannot be held responsible for the medical services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for medical 
services provided from May 5, 2022, to May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 5, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that intravenous (IV) antibiotics were 
changed on December 5, 2022, in view of the sputum culture. However, Infectious Disease consulted and noted 
to stop the antibiotic and to monitor. You say that Prednisone was continued for the enrollee's right knee gout 
attack, with a plan to perform a right knee joint tap if no improvement. You say that laboratory work revealed 
leukocytosis and low hemoglobin/hematocrit (H/H) levels.  The Plan denied your request. The Plan says the 
enrollee did not meet the criteria for a continued inpatient stay, and the records support the enrollee was stable 
and acceptable for a lower level of care.  
 
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 pay for the inpatient hospital services. Our reviewer 
says that the requested inpatient hospital services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that, as of December 5, 2022, the enrollee was hemodynamically stable. 
The intravenous antibiotics were changed on December 5, 2022, in view of the sputum culture. However, 
Infectious Disease was consulted and noted to stop the antibiotic and to monitor. The enrollee was stable on 
oral Prednisone for the treatment of gout. As of December 5, 2022, the enrollee did not require inpatient 
diagnostic studies or therapeutic interventions. She was tolerating intake by mouth. The review has determined 
that, as of December 5, 2022, inpatient hospital services were not medically necessary or reasonable. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 7, 2021, to 
November 10, 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 code 
G93.41 is supported in the documentation. The Plan denied your request. The Plan says code G93.41 is not 
supported in the documentation. 
 
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 secondary diagnosis code G93.41, defined as 
metabolic encephalopathy. 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 secondary diagnosis code G93.41 is not 
supported in the documentation. Our physician reviewer found although the provider documented metabolic 
encephalopathy, there is conflicting information throughout the chart and no query is documented to clarify the 
presence of the condition.  
 
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 November 7, 2021, to November 10, 2021, at the Diagnosis Related 
Group (DRG) originally billed.