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 just had spinal surgery and the lack of 
rehabilitation can cause the recovery to slow down and have lasting effects. The Plan denied your request. The 
Plan says your records do not show that you need an intensive team for your care. Services needed may be 
provided safely in a lower level of care. 
 
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 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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements. Services needed may be provided safely in a lower level of care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevation feature. 
 
You asked the Plan to pre-approve the seat elevation feature. You say that three payable actuators have been 
approved which require the use of E2311 to operate the three power functions. The Plan denied your request. 
The Plan says a seat elevation feature is not considered medical in nature.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided on June 6, 2022, 
by an OON provider.  
 
You asked the Plan to pay for the skilled nursing facility services. You say that you provided services in good 
faith. The Plan denied your request. The Plan says the services were 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 Plan's POS benefit only applies to non-Medicare covered 
dental services. 
 
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 skilled nursing facility services provided on 
June 6, 2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 09, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 $100 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/ultrasound 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 copayment for an 
ultrasound provided on March 09, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you broke your leg last year. You say 
that you were hospitalized this year for not being able to use your legs anymore. You also say that your 
neurologist has recommended the power wheelchair for you to get around. The Plan denied your request. The 
Plan says that the requested upgraded electronics are not medically necessary and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation shows that you require power elevating leg rests for 
positioning of your lower extremities, spasticity and lower extremity edema. The complexity of your seating 
and positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller 
with harness and electronic connection are necessary to operate the group 3 power wheelchair base and the 
three power options, including, tilt, recline and elevating leg rests, via a joystick. Therefore, the reviewer found 
that the requested upgraded electronics are 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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance transportation provided on 
August 15, 2022, to August 19, 2022. 
 
You asked the Plan to waive the copayment for each ambulance transportation. You say that you cannot afford 
the copayments. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for each ambulance transportation. This item/service falls 
within the ambulance services 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. The total amount you owe is $500 ($250 copayment x 2 transportations = $500). 
Therefore, we decided that the Plan does not have to waive the copayment for each ambulance transportation 
provided on August 15, 2022, to August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple venous procedures including intravascular 
ultrasound, followed by angioplasty and stenting with sedation and other related procedures (37238, 37239, 
99152, 75820, 75822, 36012, 37252, 37253, 75825, 36011, 76937, 99153). 
 
You asked the Plan to pre-approve multiple venous procedures. You say that the requested procedures are 
medically necessary for the enrollee. The information in this letter has clarified the reason based on published 
scientific evidence and the medical necessity for appropriately diagnosing and guiding the treatment of the 
enrollee's syndrome. The Plan denied your request. The Plan says the request is 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 multiple venous procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the procedures 
in question. There is no documentation of significant whole leg edema, and the documentation of the enrollee's 
complaints does not describe a significant enough impact on the enrollee's quality of life, daily activities, or 
mobility that would necessitate additional interventions, particularly invasive treatments. Therefore, unable to 
overturn the health plan's determination on the basis of medical necessity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple venous procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve multiple venous procedures including intravascular ultrasound, followed by 
angioplasty and stenting with sedation and other related procedures (37238, 37239, 99152, 75820, 75822, 
36012, 37252, 37253, 75825, 36011, 76937, 99153).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraoral radiographic images (D0220) and a retainer 
crown (D6740) for tooth #26. 
 
You asked the Plan to pre-approve the dental services. You say that you were told that the dental services 
would be covered at 100% so you do not understand why it was denied. The Plan denied your request. The 
Plan says your benefit for the requested items or services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) on February 23, 2023; therefore, your benefit 
for the intraoral radiographic images (D0220) was exhausted on the date of service of February 23, 2023. The 
Plan pre-approved a pontic (D6245) for tooth #24 and a retainer crown (D6740) for tooth #23 on June 19, 
2023; therefore, your benefit for the retainer crown (D6740) for tooth #26 was exhausted on the date of 
approval of June 19, 2023. Therefore, we decided that the Plan does not have to pre-approve the intraoral 
radiographic images (D0220) and a retainer crown (D6740) for tooth #26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an specialist office visit provided on 
February 13, 2023. 
 
You asked the Plan to waive the copayment for an specialist office visit. You say that you disagree with the 
copayment. 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 $10 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $10 copayment for an specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 copayment 
for an specialist office visit provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services provided on February 15, 
2023. 
 
You asked the Plan to waive the copayment for hearing services. You say that you disagree with the 
copayment. 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 $40 
copayment for hearing services. 
 
You have been asked to pay a $40 copayment for hearing services. This item/service falls within the hearing 
services 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 copayment for hearing services provided 
on February 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the diagnostic mammogram provided on November 7, 
2022. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you do not agree with the 
copayment. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the complete correct 2022 Evidence of Coverage 
(EOC). Therefore, we decided that the Plan has to waive the copayment for the diagnostic mammogram 
provided on November 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement cover for wheelchair seat cushion or 
back cushion, each (E2619). 
 
You asked the Plan to pre-approve the replacement cover. You say that you are aware that the following items 
included in the current submission request are typically non-covered and request a formal mixed decision in 
order to pursue other funding resources for these items. The Plan denied your request. The Plan says this is not 
a medically necessary accessory and does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement cover have not been met. Therefore, we decided that the Plan does not have to pre-
approve the replacement cover for wheelchair seat cushion or back cushion, each (E2619).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 02, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services 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 an office visit and 
related services provided on February 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 15, 2022, to 
May 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.51, described as 
Sepsis due to Escherichia coli [E. coli], and secondary diagnosis code R65.20, described as Severe sepsis 
without septic shock. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed codes. 
Our physician reviewer found that the enrollee is an 83-year-old female with dementia who presented to the 
hospital with altered mental status and hyperglycemia. She was treated with her home meds and mental status 
improved. Vitals were stable on room air. She was alert and oriented x 3. However, workup revealed gall 
bladder disease causing leukocytosis and elevated liver enzymes and bilirubin requiring cholecystectomy. 
Blood cultures were positive, and she was given fluids, antibiotics, and insulin. Platelets were normal, there 
was no oliguria documented, vitals remained stable, and kidney function was stable/normal. Based on the 
above findings, the patient had an acute condition/infection but there was insufficient evidence of a 
dysregulated response leading to life-threatening organ failure to meet Sepsis 3 criteria. Therefore, the sepsis 
codes, A41.51 and R65.20 are both not justified for this admission.   
 
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 May 15, 2022, to May 25, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 13, 2023, to 
February 11, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted electronically on 
January 16, 2023. The Plan denied your request. The Plan says despite you the fact that you indicated that the 
NOA has been submitted, the Plan contends they have not received it. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the Plan has confirmed that they have still not received the required NOA, so no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 13, 2023, to February 11, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care services provided on January 04, 
2023. 
 
You asked the Plan to pay for the mental health care services. You say that you would like payment on this 
claim to be reconsidered. 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 mental health care 
services provided on January 04, 2023.