Persius/hicric huggingface dataset:
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  
 
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 arterial thrombosis of the leg. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, in 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.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injections provided on March 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the therapeutic injections. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has 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 the therapeutic injections provided on March 1, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with an out-of-network (OON) 
Neurosurgeon. 
 
You asked the Plan to pre-approve office visits with an out-of-network (OON) Neurosurgeon. You say that the 
request to see an OON Neurosurgeon is medically necessary.  The Plan denied your request. The Plan says the 
enrollee can wait to be seen by an in-network Neurosurgeon scheduled for October 30, 2023.  
 
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 office visits with out-of-network 
(OON) Neurosurgeon. Our reviewer says that the request to see an OON Neurosurgeon is not medically 
necessary.  Our physician reviewer found the member was found to have a cerebral aneurysm on imaging. His 
aneurysm is largely asymptomatic based on the description provided. There was no indication that the member 
requires urgent or emergent surgical intervention for their condition. In as much it would otherwise be 
appropriate for the member to wait until the end of October for a consult with the in-network Neurosurgeon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visits with out-of-network (OON) Neurosurgeon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve office visits with an out-of-network (OON) 
Neurosurgeon.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete breast ultrasound (76641) provided on April 27, 
2022. 
 
You asked the Plan to pay for the complete breast ultrasound. You say that you would like the Plan to 
reconsider paying this claim. The Plan denied your request. The Plan says this claim was processed correctly 
due to the claim not being filed until May 24, 2023, without good cause. The Plan also says that this means 
more than one calendar year from the date of service had passed before the claim was filed. 
 
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 complete breast ultrasound was not filed until May 24, 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 complete breast ultrasound (76641) provided on April 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3334) and (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that your left leg is two centimeters short due to a 
knee surgery you had on your right knee, which is causing you to limp. You also say that it is now affecting 
your hip and you need these heel lifts to walk better and feel this is causing delay in your care. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3334) and 
(L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and therapeutic procedure provided by a 
chiropractor on May 9, 2023. 
 
You asked the Plan to pay for the office visit and therapeutic procedure. The Plan denied your request. The 
Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit and therapeutic procedure provided by a chiropractor on May 
9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801). 
 
  You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. You say that you were 
crawling up the stairs of your trailer, and have recently had your legs amputated. You also say that you were 
told the scooter was approved. The Plan denied your request. The Plan says the notes indicate that no home 
evaluation was done because it is known that your home will not accommodate this device. The Plan also says 
in addition, it appears that you do not currently have a ramp on your home to get the requested device inside. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. Medicare rules also say that prior to or at the time of delivery of a POV or PWC, the supplier or 
practitioner must perform an on-site evaluation of the beneficiarys home to verify that the beneficiary can 
adequately maneuver the device that is provided considering physical layout, doorway width, doorway 
thresholds, and surfaces. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a group 1 heavy duty power operated 
vehicle have been met. Specifically, the provided documentation does not include records of a home 
assessment that was done. Therefore, we decided that the Plan does not have to pre-approve a group 1 heavy 
duty power operated vehicle (K0801).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 3, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this claim must first be submitted to the enrollee's primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), intraoral  comprehensive 
series of radiographic images (D0210), topical application of fluoride varnish (D1206), caries risk assessment 
and documentation, with a finding of high risk (D0603), periodic oral evaluation - established patient (D0120), 
and oral hygiene instructions (D1330) provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider is in-network with the plan. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis - adult (D1110), intraoral  comprehensive series of radiographic images (D0210), 
topical application of fluoride varnish (D1206), caries risk assessment and documentation, with a finding of 
high risk (D0603), periodic oral evaluation - established patient (D0120), and oral hygiene instructions 
(D1330) provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 30, 2023, to 
March 27, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you are a widow that lives alone and are 
suffering from chronic idiopathic polyneuropathy, which may cause chronic pain, nocturnal leg cramping that 
disrupts sleep, balance issues and leg weakness. The Plan denied your request. The Plan says The requested 
service is not covered by Medicare or the Health Plan. 
 
  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, you stated that you have chronic leg pain. However, 
the Plan only covers acupuncture for low back pain. Therefore, we decided that the Plan does not have to pay 
for acupuncture services provided on January 30, 2023, to March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on May 2, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been getting chiropractic treatments 
without an issue for years. You say that you do not believe you should be held liable for the entire bill, just 
your copay. The Plan denied your request. The Plan says The Plan says the only covered chiropractic service is 
manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 16, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has 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 the office visit provided on May 16, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on March 
16, 2023, and an aricimab-svoa injection provided on May 11, 2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were not advised of the high 
expense. 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 20% 
coinsurance for Medicare Part B drugs when administration or observation by medical personnel is required, 
and the drugs are administered to you by a network provider. 
 
You have been asked to pay $637.14, which is less than 20% coinsurance of the allowed amount for the 
injection provided on March 16, 2023. You have also been asked to pay $893.28, which is less than the 20% 
coinsurance of the allowed amount for the injection provided on May 11, 2023. These items/services fall within 
the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an aflibercept injection provided on March 16, 2023, and an aricimab-svoa injection provided on May 11, 
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 therapy to build strength which 
can only be done in an inpatient rehabilitation facility. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility, home with home health services or home with outpatient therapy.  
 
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 was admitted for congestive heart failure and pericardial effusion. 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.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee 's first injection provided 75% pain 
relief. The Plan denied your request. The Plan says that epidural steroid injections are not medically necessary.  
 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 injections. Our reviewer says that 
epidural steroid injections are not medically necessary. Our physician reviewer found that there is no role for a 
series of three injections, as each injection must be evaluated for efficacy and duration before another will be 
approved. Also, the LCD requires that each injection produce at least 50% pain relief for three months, which 
has not passed yet. Therefore, the request is not medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not informed your benefit was 
exhausted prior to the procedure. The Plan denied your request. The Plan says your benefit for the requested 
item or service 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 the requested item or service was exhausted on date of service November 8, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on August 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that your dentist told you to go to this office. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit 
when received from an out-of-network provider.  Therefore, we decided that the Plan does not have to pay for the consultation - diagnostic service provided by 
dentist or physician other than requesting dentist or physician (D9310) provided on August 1, 2023.