Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 18, 2022, to 
July 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there was a system issue beyond 
your control. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 18, 2022, to July 
17, 2022.
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 fell and are not able to go back to everyday 
functioning after having hip replacement surgery. You say the IRF does a three hour extensive training for 
rehabilitation that you need. The Plan denied your request. The Plan says you do not meet the Medicare 
guidelines for services in an IRF.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 25, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel the bill you 
received is incorrect. 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 $375 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for any additional days of the same in-network inpatient 
hospital stay. 
 
You have been asked to pay a $375 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,875 for the inpatient hospital 
stay ($375 copayment per day x 5 days = $1,875). 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 
the inpatient hospital stay provided from January 25, 2023, to January 31, 2023.
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 more than willing to do anything to get your 
strength and ability back to normal. The Plan denied your request. The Plan says a SNF admission 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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: 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 if the enrollee is very motivated to get back to prior 
level of function. The Plan denied your request. The Plan says the enrollee's records do not show to have 
complex rehabilitation needs requiring frequent evaluation by a rehabilitation doctor. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 28, 
2023, to February 1, 2023. 
 You asked the Plan to pay for SNF care. You say that the services provided are coverable under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pay for skilled nursing facility (SNF) care provided from January 28, 2023, to February 1, 2023.
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 this is medically necessary. The Plan denied your 
request. The Plan says the IRF benefit is not appropriate for enrollees who have completed their full course of 
treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available 
for such enrollees in a less-intensive setting. this 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 there is not a reasonable expectation that this patient 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy (G0151 x6). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee is home bound. Clinical documentation shows that the enrollee has 
multiple complicating medical comorbidities (arthritis of multiple joints) currently undergoing assistive device 
evaluation, requires moderate assist with transfers and ambulation and has recently begun treatment with 
physical therapy and making functional progress. The records show that skilled therapy services are required in 
the home setting to effectively provide treatment, care, and/or services in order to improve the enrollee's level 
of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health physical therapy (G0151 x6).  
 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: 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 the enrollee's health has declined, and they have lost 
mobility. You say that the enrollee's provider indicates additional physical therapy, occupational therapy, and 
speech therapy will help them return to their baseline. The Plan denied your request. The Plan says based on 
Medicare guidelines, the SNF services requested do not meet the requirements for approval.  
 
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 the enrollee does not have daily 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #4, #6, #11, #13, and 
#15, pontics (D6245) for tooth #5, #12, and #14, and retainer crowns (D6740) for tooth #4, #6, #11, #13, and 
#15. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee cannot eat without the bridge 
being completed. The Plan denied your request. The Plan says the enrollee is missing teeth on both sides of the 
arch; therefore, the coverage criteria was not met for the core buildup, pontics, and retainer crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the core buildup, pontics, and retainer crowns do not meet the criteria for coverage. Our physician reviewer 
found that the documentation indicates that coverage for a fixed bridge is limited to the replacement of a single 
maxillary anterior tooth or 2 adjacent mandibular anterior teeth and if no posterior teeth are missing in the arch. 
In this case there are missing posterior teeth bilaterally in the maxillary arch tooth #5, #12, and #14. Since the 
fixed bridges replacing missing teeth #5, #12, and #14 are not eligible for coverage, the subsequent core 
buildups and retainer crowns are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the core buildup (D2950) for tooth #4, #6, #11, #13, and #15, pontics (D6245) for 
tooth #5, #12, and #14, and retainer crowns (D6740) for tooth #4, #6, #11, #13, and #15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 25, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that the items should be covered. 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 wound care supplies 
provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 16, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for physician services. You say that you want to reconsider payment. The Plan 
denied your request. The Plan says the provider is not a network 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 physician services provided on March 16, 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 a wig, a hair replacement service (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you are needing the cranial prosthesis due to hair loss 
from Alopecia, not for cosmetic reasons. The Plan denied your request. The Plan says you do not have a 
supplemental benefit for wigs/hair replacement that goes beyond the Medicare benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig, a hair 
replacement service (A9282).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a contact lens fitting (92310) provided on February 1, 2023. 
 
You asked the Plan to pay for a contact lens fitting (92310). You say that charges for a refraction should have 
been covered. The Plan denied your request. The Plan says that contact lens fitting is not a covered expense 
under your vision care program. The Plan also says your benefit does not include a carve out for a contact lens 
evaluation fitting and follow-up; it must be used at the same time and place that you use the contact lens 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed in a specialist physician setting at any participating 
network provider location once every calendar year. 
 
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. 
 
 
  We looked at the file and the Plan's rules. The Plan contract also says that the Plan covers one routine eye exam 
every calendar year, inclusive of dilation (when professionally indicated), performed in a specialist physician 
setting at any participating network provider location. The Plan contract also says that routine eye exams, 
fitting/evaluations, and eyewear do not apply to the maximum out-of-pocket. The record shows that routing eye 
examinations, fitting/evaluations are covered. There was no evidence provided that shows that a contact lens 
fitting is not a covered expense under the Plan. Specifically, the Medical Benefits Chart, does not show that a 
contact lens fitting (92310) must be done at the exact time the contacts are ordered. Based on this information, 
we decided that the Plan's rules for coverage of a contact lens fitting (92310) have been met. Therefore, we 
decided that the Plan has to pay for a contact lens fitting (92310) provided on February 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 additional routine transportation trips. 
 You asked the Plan to pre-approve the additional trips. You say that the additional trips are needed because you 
are being evaluated for your injured hip at least once every two weeks. The Plan denied your request. The Plan 
says routine transportation benefits beyond the 100 allotted one-way trips are not covered under the plan. 
 
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 100 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 25 additional routine transportation trips.