Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the sand scooter rental, sales tax, and delivery 
provided from September 2, 2023, to September 8, 2023. 
 
You asked the Plan to reimburse you for the durable medical equipment. You say that you were told that as 
long as your doctor wrote a letter stating you needed it that you would be reimbursed 80%. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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. Additionally, sales tax is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to reimburse you for the sand scooter 
rental, sales tax, and delivery provided from September 2, 2023, to September 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care before returing home. 
The Plan denied your request. The Plan says medical records do not support the need for an IRF admission and, 
the enrollee needs can be safely provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transvaginal ultrasound (76830) and pelvic ultrasound 
(76856).   
You asked the Plan to pre-approve a transvaginal ultrasound and pelvic ultrasound. You say that you need to 
get the ultrasound done by obstetrics and gynecology provider because the doctor knows exactly what needs to 
be done. You also say that you have been going to this provider for a period of time and the requested provider 
knows in depth about your condition and you feel more comfortable if the ultrasound is done at their office. 
The Plan denied your request. The Plan says the requested provider is not contracted to provide these services. 
 
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 a transvaginal ultrasound and pelvic 
ultrasound. Our physician reviewer found the record indicates that you have abnormal pelvic ultrasound 
findings and require the requested services. The record provided documents that network providers are 
available or adequate to meet your medical needs. Our reviewer found that the elements of the coverage criteria 
are not satisfied.  Our physician reviewer also found that the requested service is not recommended. 
 
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 transvaginal ultrasound and pelvic ultrasound have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a transvaginal ultrasound (76830) and pelvic ultrasound 
(76856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit provided by in-network 
provider on May 15, 2023. 
 
You asked the Plan to waive the cost share for the office visit. You say that you only went to the doctors to get 
a prescription renewed and shouldn't have to pay the deductible. 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 there is a $800 
deductible or a $1,7000 out-of-pocket maximum that applies to in and out-of network office visits. The plan 
contract also says that enrollees must pay a 10% coinsurance of the approved amount for in and out-of-network services. The coinsurance for this plan is applied before and in addition to the deductible amount. There is also 
a $90 coinsurance/copay maximum. 
 
At the time the claim was received the member had a $0 copayment, $25.16 coinsurance, and a $226.62 
deductible amount. The Plan to waive the deductible for falls within the doctor and other health care provider 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $800 deductible which applies to an in-network office visit. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $800 deductible which applies to out-of-network office visit. 
This cost sharing is a contractual obligation that had not been met at the time the office visit provided on May 
15, 2023. 
 
You have been asked to pay $128 which is 10% coinsurance of the allowed amount since the deductible still 
has not been met at the time of the office visit on May 15, 2023. ($120.08 coinsurance/deductible + $4.12 
coinsurance/deductible + $4.12 coinsurance/deductible = $128). These services fall within the Doctor and other 
health care provider services for in and out-of-network. This means 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 cost share for the 
in-network office visit provided from May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7953 and D0367). 
 
You asked the Plan to pre-approve the dental services (D7953 and D0367). You say that you would like to 
request reconsideration of the denied dental services and that the services requested are medically necessary. 
The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services (D7953 and D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that this is medically necessary and reasonable to treat 
the enrollee. The Plan denied your request. The Plan says this is not medically necessary for superficial 
radiation therapy. 
 
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 US-IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer, but is not necessary. This would 
not be furnished in accordance with accepted standards of medical practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that the requested services are a necessity for 
your care. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no indication that acupuncture is sought in 
this case for the treatment of CLBP. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for admission to 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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable, and 
there are no complex nursing or rehabilitation needs. Medically necessary services can be provided in a lower 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is medically necessary to 
regain maximum function. The Plan denied your request. The Plan says inpatient rehabilitation 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 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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports 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 this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you require an LTACH level of care for 
ongoing transfusions, physical and occupational therapy and nursing care. The Plan denied your request. The 
Plan says that the request for LTACH services to be covered does not meet the requirements for approval. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found you currently do not require hospitalization in the short term acute care hospital. However, due 
to the complex nature of your medical condition attempts at placement have been denied. You will need 
ongoing management of transfusion dependent anemia and intensive rehabilitation. The requested LTACH 
services are medically reasonable, necessary and appropriate. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an IRF admission to become 
strong enough to return home and live independently. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, but skilled therapies as an outpatient, home with home healthcare, or at a 
skilled nursing facility (SNF) may be approved upon request.  
 
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. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for pathology services (88305, 88307, 88313, 88331, 88341 and 88342) 
provided on March 15, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and 
was correctly denied. In addition, some services were reported with inappropriate modifiers. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. The rules 
also 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 Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has provided no evidence that 
any service on this claim has previously been paid. In addition, the Plan has not clearly explained what issue 
exists with the modifier used on certain items and has not provided a citation or review to support this denial. 
Based on this information, we decided that Medicare rules for coverage of pathology services have been met. 
Therefore, we decided that the Plan has to pay for pathology services (88305, 88307, 88313, 88331, 88341 and 
88342) provided on March 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of 75% improvement in pain relief measured from the 
enrollee's baseline. Therefore, the criteria for coverage have not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to the IRF 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 the enrollee does require physical therapy and occupational therapy services, but the 
medical records provided do not clarify why the enrollee requires an intensive inpatient rehabilitation therapy 
program. Provided medical records do not support that the intensive inpatient rehabilitation therapy program is 
necessary and that therapy at a lower level of care such as in a skilled nursing facility (SNF) is not appropriate 
for the enrollee. Based on the medical records provided, the enrollee would be expected to participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
However, the medical records do not support a complexity of needs to require an IRF with an interdisciplinary 
team over a SNF.  
 
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.