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 you need physical and occupational therapy to get 
stronger and become more independent at home. You also say that you want to be seen by a doctor daily, and 
need all day nursing care. The Plan denied your request. The Plan says criteria for admission to the Acute 
Inpatient Rehabilitation setting have not been met.  
 
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 is medically stable with no acuity and does not need a physical medicine 
and rehabilitation physicians supervision 3 times a week in an IRF. No acute rehabilitation skilled nursing 
needs are identified or documented. The enrollee needs routine physical therapy and occupational therapy, but 
does not need specialized intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. Our reviewer found that the document does not support 
necessity for admission to an IRF. With no medical acuity, and no rehabilitation nursing needs as described 
above the enrollee does not require an IRF stay. Our physician reviewer also found that the enrollees 
rehabilitation needs can be provided in an alternate and low intensity setting such as in a skilled nursing 
facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitoring supplies billed for date of 
service August 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that relevant documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records show that medications were changed which eliminated the need for close 
glucose monitoring as the enrollee would not be insulin dependent. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitoring supplies billed for date of service August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed for date of 
service August 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that relevant documentation was provided. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records do not support that the provided supplies were ordered to treat the enrollees 
condition. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies 
billed for date of service August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the notes do not show a medical need to control the 
power options with the joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested electronic connection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested electrical accessory is not medically necessary as the enrollee does 
have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for upgraded electronics. Therefore, the reviewer found that the requested electronic connection is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental health stay provided 
from December 5, 2022, to December 9, 2022. 
 
You asked the Plan to waive the copayment for the inpatient mental health stay. You say that the service was 
unsuccessful. 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 $310 
copayment per day, for days one to six and a $0 copayment per day, for days seven to ninety for inpatient 
mental health care. 
 
You have been asked to pay a $1,114.94, which is less than the standard copayment for the inpatient mental 
health stay. This item/service falls within the inpatient mental health care benefit category. The record show 
you have met your maximum out-of-pocket amount during this service. 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 mental health stay provided from December 5, 2022, to December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist-hand-finger orthosis (WHFO) (L3807). 
 
You asked the Plan to pay for the WHFO. You say that the item should be covered. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to durable medical equipment (DME) 
and related supplies.  
 
The item or service you asked the Plan to pay for falls within the durable medical equipment (DME) and 
related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $750 deductible which applies to durable medical equipment (DME) and related supplies. This 
cost sharing is a contractual obligation that had not been met at the time the WHFO was received on September 
19, 2023. Therefore, we decided that the Plan does not have to pay for the wrist-hand-finger orthosis (WHFO) 
(L3807).
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 is clinically stable to 
discharge from the current setting to an LTACH level of care, and the LTACH is both the enrollee's and 
physicians' choice for optimal treatment. The Plan denied your request. The Plan says they will continue to 
cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for 
transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical circumstances 
change such that LTACH may be reconsidered.  
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. 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 health plan. Given there are offered alternatives, LTACH is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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 pay for the periodontal scaling and root planing (D4341 x 2) and 
therapeutic drug (D9610 x 2) provided on October 18, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary due to the 
enrollee's condition. The Plan denied your request. The Plan says services received out-of-network are not 
covered. 
 
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 pay for the 
periodontal scaling and root planing (D4341 x 2) and therapeutic drug (D9610 x 2) provided on October 18, 
2023, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have dementia, are a fall risk, and are not safe 
to go home. You also say that your primary caretaker will be away short term, and your spouse is unable to 
care for you at this time. The Plan denied your request. The Plan says a skilled nursing facility level of care for 
short term rehabilitation is not reasonable and 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 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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on 
September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 June 27, 2023. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on 
September 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion using a Minuteman device. 
 
You asked the Plan to pre-approve lumbar fusion using a Minuteman device.. You say that the surgery is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the surgery (when using that 
specific device) is experimental/unproven. 
 
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 lumbar fusion using a Minuteman 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Our physician reviewer found in this case, the 
requested Minuteman device at L4-5 is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion using a Minuteman device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lumbar fusion using a Minuteman device.
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 an LTACH would be able to provide 
care for the enrollee's conditions in an extended acute care setting. The Plan denied your request. The Plan says 
with additional time in the current setting, clinical stability can be ensured such that the appropriate lower level 
of care can be determined. 
 
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 the enrollee appears to be improving with current treatment but is still somewhat 
unstable and requires additional acute care hospital services that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee does not require LTACH services that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as 
the enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of 
treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 26, 2022, 
to December 29, 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 
medical record supports the diagnoses billed. The Plan denied your request. The Plan says there is not 
sufficient documentation to clinically validate the diagnosis codes for Sepsis, unspecified organism (A41.9) or 
Myocardial infarction type 2 (I21.A1). The more appropriate principal diagnosis is Cellulitis of face (L03.211). 
As a result, a lower DRG was paid. 
 
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 diagnoses of Sepsis, unspecified organism (A41.9) 
and Myocardial infarction type 2 (I21.A1).. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that the billed diagnoses of Sepsis, 
unspecified organism (A41.9) and Myocardial infarction type 2 (I21.A1) are not supported by the medical 
record. Our physician reviewer found the enrollee presented with facial pain and redness. He was diagnosed 
with facial cellulitis and hospitalized for treatment. There is no evidence that the enrollee had sepsis (ex. 
hypotension, hypoperfusion, organ failure). There is no evidence that the enrollee suffered a myocardial 
infarction (i.e., heart attack).  As such, the billing of A41.9 and I21.A1 is not supported.  
 
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 December 26, 2022, to December 29, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
inserts (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from November 12, 2022, to November 16, 2022. 
 
You asked the Plan to pay for IRF care. You say that the services were medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show you needed to be seen by a rehabilitation 
doctor at least three times a week for evaluation of functional and medical goals and progress.  
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 pay for 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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from November 12, 
2022, to November 16, 2022.