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

 
We decided that the Plan has to pay for inpatient hospital services billed with diagnosis code D50.9 rendered 
from June 7, 2022, to June 11, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that a post-service, post-payment DRG audit 
was performed. 
 
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 DRG 811. 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 services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee presented with weakness and shortness of breath.  He was found to be severely anemic. While 
there was concern for congestive heart failure, the cardiologist did not believe that the enrollee had heart failure 
and promptly signed off. The enrollee was, however, transfused, evaluated by gastroenterology, scoped and 
given iron. As such, it appears that the primary reason for hospitalization was iron deficiency anemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed.  Therefore, we decided that the Plan has to pay for inpatient 
hospital services billed with diagnosis code D50.9 rendered from June 7, 2022, to June 11, 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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services in order to return 
home at their maximum level of functioning with a decreased risk for readmission. The Plan denied your 
request. The Plan says the request 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 enrollees 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 IRF admission and services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on September 12, 2022.  
 
You asked the Plan to pay for the emergency room services. You say that this should be paid with the billed 
diagnosis code. The Plan denied your request. The Plan says that the diagnosis code is missing the required 
detail of laterality. 
 
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 Plan's denial rationale does not appear to be appropriate in this case. The 
Plan cited coding guidelines which require that laterality be reported when known from the records, stating that 
the billed diagnosis code inappropriately indicates an unspecified side. Review of the diagnosis code, however, 
shows that the code reported, S46.912A, does specify that the condition occurs on the left side, which is 
supported by the records. The only unspecified component of the code is the muscle, tendon, or fascia in which 
the strain occurred. The specific muscle, tendon, or fascia that was strained would not necessarily be known by 
the emergency room physician. As such, we find no deficiency in the code billed, and we find that the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the emergency room services 
provided on September 12, 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: Favorable

 
We decided that the Plan has to pay for the inpatient physician services provided from July 6, 2022, to July 8, 
2022.  
 
You asked the Plan to pay for the physician services. You say that this should be paid as the services were 
medically necessary. The Plan denied your request. The Plan says that an appeal review was not completed as 
the case was untimely. 
 
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 Plan has not provided a valid denial rationale in this case. It appears that the 
Plan's denial may be related to the Independent Physician Association (IPA) needing to pay the claim. 
However, the IPA is considered an agent of the Plan, and the Plan is ultimately responsible for payment of 
covered services. Since no evidence was submitted showing that the IPA did make payment, nor that the 
hospital stay was billed as outpatient, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the inpatient physician services provided from July 6, 2022, to 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
radiation treatments. The Plan denied your request. The Plan says you have exhausted your transportation 
benefit. 
 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 additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve zolmitriptan. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 zolmitriptan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an out-of-network tertiary provider. 
 
You asked the Plan to pre-approve the outpatient service. You say that you had a spot taken off your skin that 
came back as cancer. You say that this is an urgent request. You also say that this is medically necessary.  The 
Plan denied your request. The Plan says the request to see an out-of-network tertiary provider is not medically 
necessary. The Plan also says that an office visit with a network provider has been approved. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient service. Our reviewer 
says that the request for an office visit with an out-of-network tertiary provider is not medically necessary. Our 
physician reviewer found the provided documentation does not support that there is anything unique about the 
enrollee's condition that that would make it medically necessary to see the requested out-of-network tertiary 
provider. The reviewer found that the Plan shown that they have in-network providers who meet the Standards 
of Care required for treatment of the enrollee's condition. Therefore, the reviewer found that the requested 
office visit with an out-of-network tertiary provider is not medically necessary. 
 
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 outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit with an out-of-network tertiary provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee is unable to ambulate within their home to complete MRADLs within a reasonable time frame. You 
say that the enrollee's mobility limitations cannot be resolved with a cane, walker, manual wheelchair or 
scooter. You also say that this is medically necessary for the enrollee.  The Plan denied your request. The Plan 
says a Group 3 power wheelchair with multiple power options is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options. Our reviewer says that a Group 3 power wheelchair with multiple power options is not 
medically necessary. Our physician reviewer found the provided documentation does not support that the 
enrollee was at high-risk for skin breakdown, uses an intermittent catheter, or has spasticity. Therefore, the 
reviewer found that a Group 3 power wheelchair with multiple power options is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 22, 2022, to 
August 7, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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, described 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee has a baseline dementia. Her underlying cognitive 
condition was exacerbated by an active infection. There was no clinical or laboratory evidence of metabolic 
encephalopathy.   
 
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 July 22, 2022, to August 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the hospital's contracted rate.  
The Plan must follow Medicare rules. Medicare rules say that for outpatient nondiagnostic services furnished 
on or after June 25, 2010, all outpatient nondiagnostic services, other than ambulance and maintenance renal 
dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on 
the date of a beneficiary's inpatient admission are deemed related to the admission, and thus, must be billed 
with the inpatient stay.  
 
We looked at the file and Medicare rules. In this case, payment for the requested services is included in the 
hospital inpatient payment. The services are not separately payable. 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 the services provided on July 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the gym memberships to Planet Fitness and the YMCA. We decided 
that the Plan does not have to pay for the gym membership to Planet Fitness.  
 
You asked the Plan to pay for the gym memberships to Planet Fitness and the YMCA paid for between April 1, 
2022, and December 16, 2022. The Plan says that the Plan has not received any additional proof of payment for 
the remaining membership months of April to August for Planet Fitness or the membership to the YMCA. 
 
We decided that the Plan has to pay for the gym membership to the YMCA.  
 
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 case file includes proof of payment for YMCA gym membership fees paid 
from November 10, 2022, to December 16, 2022, totaling $92. The records do not support the Plans denial 
reason, that proof of payment was not submitted for the YMCA gym membership. This means that the Plan has 
not provided a valid reason for denying payment of the gym membership to the YMCA. There was no 
information provided showing the Wellness Allowance has been exhausted. It is the burden of the Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated. Therefore, we 
decided that the Plan has to pay for the gym membership to the YMCA.  
 
We also decided that the Plan does not have to pay for the gym membership to Planet Fitness. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
when a Wellness Allowance reimbursement form along with proof of payment and any additional information 
outlined on the form are submitted. 
 
You asked that the Plan reimburse you $159 for a gym membership to Planet Fitness. The record shows that 
proof of payment for the gym membership to Planet Fitness was submitted for January 3, 2022, to March 17, 
2022, and from September 19, 2022, to December 19, 2022, totaling $109. The records show that the Plan 
issued reimbursement for this amount. The rules for coverage of gym benefits have not been met for the 
remaining balance of your reimbursement request because there is no proof of payment for the remaining $50. 
Therefore, we decided that the Plan does not have to pay more for the gym membership to Planet Fitness. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dorsiflexion and/or plantar flexion control (L5973). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says numerous K3 feet are available that will allow the enrollee to continue proposed outdoor 
activities. The Plan also says that no activity demands are noted that cannot be met with K3 mechanical foot. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the documentation does not support that the enrollee is a K3 ambulator, given the need for a power 
wheelchair for activities of daily living (ADLs). Also, the physician documentation does not support why the enrollee's functional needs cannot be met with a mechanical foot over a microprocessor foot. This request 
exceeds the enrollee's needs. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a dorsiflexion and/or plantar flexion control (L5973).