Persius/hicric huggingface dataset:
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 submitted medical records support the need for 
IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
we have about the enrollee's condition they do not meet all of the requirements. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for an intracranial hemorrhage. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T12 kyphoplasty. 
 
You asked the Plan to pre-approve the T12 kyphoplasty. You say that the enrollee has severe pain and unable 
to ambulate. The appellant says the enrollee has an acute compression spinal fracture. The Plan denied your 
request. The Plan says the T12 kyphoplasty because the enrollee's fracture demonstrates retropulsion with canal 
compromise at T12 which meets the exclusion criteria. 
 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 T12 kyphoplasty. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is bone retropulsion at the fracture level which is a contraindication. 
 
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 T12 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the T12 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on February 16, 2023. 
 You asked the Plan to pay for the vision supply. You say that you believe you should be reimbursed $100 as 
your benefit states The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $100 combined allowance for eyeglasses and contact lenses 
every 12 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 towards eyewear services on 
October 10, 2022, which exhausted the benefit. Please note, the February 16, 2023, date of service is within the 
12-month time frame. Based on this information, we decided that the Plan's rules for coverage of the vision 
supply have not been met. Therefore, we decided that the Plan does not have to pay for the vision supply 
provided on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria, and 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the enrollee does not meet the guidelines for LTACH services.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210, D7140) and implants and related 
services (D6010, D6104, D6056). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the extractions 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 your benefit for extractions was exhausted and implants are not covered when related to a major non 
covered service. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210, D7140) 
and implants and related services (D6010, D6104, D6056).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 00731 provided on March 3, 2023. 
 
You asked the Plan to pay for procedure code 00731. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan denied payment for procedure code 00731 because of the 
billing of diagnosis code I10.  However, the file does not include a claim that shows that procedure code 00731 
was billed with diagnosis code I10. The claim shows that diagnosis codes C16.9 and Z98.0 were billed with 
procedure code 00731. The Plan has not provided any other reason for the denial. Therefore, we decided that 
the Plan has to pay for procedure code 00731 provided on March 3, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the Plan agreed to work with this physician a year ago. The Plan denied your request. 
The Plan says the service is available in-network, there is no continuity of care, and the service is not urgent. 
 
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot care/nail trimming. 
 
You asked the Plan to pre-approve foot care/nail trimming. You say that you have physical limitations that 
prevent you from giving yourself any routine footcare. The Plan denied your request. The Plan says the 
member does not have a diagnosis of diabetes or a foot at risk. The member was referred for consultation for a 
callous and an ingrown toenail. Toenail trimming can be provided as a fee-for-service. 
 
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 pre-
approve are routine foot care services. Therefore, we decided that the Plan does not have to pre-approve foot 
care/nail trimming.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say you have several medical complications, and this physician has all of your medical records 
and you do not want to start treatment with a new provider as your care is too complicated and you do not want 
to risk being sick with a new provider. The Plan denied your request. The Plan says given that there are in-
network providers at in-network facilities that would meet your needs; having care with an in-network provider 
at an in-network facility would not be detrimental to your health; and it is not medically necessary for you to 
see a specialist or subspecialist rendering services outside of the network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on March 23, 2023, by an 
out-of-network (OON) provider.  
 
  You asked the Plan to pay for the eye exam. You say that the enrollee was in a nursing home setting at the time 
services were rendered, and they could not choose an in-network optometrist. You also say that the provider 
has no knowledge of which patients they will see until they arrive at the facility. The Plan denied your request. 
The Plan says this service was rendered by an OON provider and an authorization was not obtained for the 
services provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92014) provided on March 23, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg with a microprocessor foot feature, 
vacuum socket, and shock reducing pylon. 
 
You asked the Plan to pre-approve prosthetic leg with a microprocessor foot feature, vacuum socket, and shock 
reducing pylon. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prostheses and accessories are only covered for 
certain indications. 
 
 
 
 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 prosthetic leg with a microprocessor 
foot feature, vacuum socket, and shock reducing pylon. Our reviewer says that the documentation does not 
support that the requested items are medically reasonable or necessary. Our physician reviewer found the 
treating medical physician provider documentation does not support that the enrollee requires a heavier 
microprocessor foot for the enrollee's functional activities over a mechanical foot.  The physician 
documentation does not support that the enrollee's activities and functions require a shock reducing pylon 
feature. Additionally elevated vacuum suspension for residual limb volume management and moisture 
evacuation systems among lower extremity amputees is unproven and not medically necessary due to 
insufficient evidence of safety and/or efficacy. The physician documentation does not support the need for the 
elevated vacuum suspension system. The requested items exceed the enrollee's medical and functional 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 prosthetic leg with a microprocessor foot feature, vacuum socket, and shock 
reducing pylon have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic 
leg with a microprocessor foot feature, vacuum socket, and shock reducing pylon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 2, 2022, to 
October 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 G03.8, described as 
Meningitis due to other specified causes. 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 is a 54-year-old with neurosarcoidosis and 
interstitial lung disease who was treated in the hospital with infliximab, steroids for pachymeningitis directly 
due to the sarcoid. However, the secondary diagnosis of meningitis (G03.8) was not sufficiently supported in 
the documentation. The notes describe no other cause of the meningitis other than the sarcoidosis which would 
mean sarcoid meningitis (D86.81) would be a more appropriate secondary diagnosis for this admission 
according to the provided documentation.   
 
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 October 2, 2022, to October 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and removal of eyelashes provided on 
November 15, 2021. 
 
You asked the Plan to pay for the physician services. You say that the claim was originally paid on November 
30, 2021. You say that it was determined there was a billed error on the claim. You also say that you lost the 
dedicated office biller before a corrected claim could be issued. The Plan denied your request. The Plan says 
the claim was not filed within one year of the date of service. 
 
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 the physician services was not filed until January 6, 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 the office visit and removal of eyelashes provided on November 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92012) provided on September 22, 
2022, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for an eye examination with an out-of-network provider. You say that the nursing 
home was responsible to obtain prior authorization. The Plan denied your request. The Plan says this provider 
is out-of-network. There was no authorization for the services provided, and the services were not referred by a 
participating provider. 
 
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 eye examination (92012) provided on 
September 22, 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 three scanning computerized ophthalmic diagnostic 
imaging visits (92134 x3) and three fundus photographies with interpretations and reports (92250 x3) to be 
provided by an out-of-network (OON) provider.  
 You asked the Plan to pre-approve the scanning computerized ophthalmic diagnostic imaging visits and fundus 
photographies. The Plan denied your request. The Plan says from the records received, no medical need is 
shown as to why the enrollee cannot get this health care service from a provider in the Plan's network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
three scanning computerized ophthalmic diagnostic imaging visits (92134 x3) and three fundus photographies 
with interpretations and reports (92250 x3) to be provided by an out-of-network (OON) provider.