Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.  
The Plan denied your request. The Plan says the records do not show that is it medically necessary to be in an 
LTACH in place of an acute care hospital.  
 
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 somewhat unstable and requires additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service December 9, 
2022. 
 You asked the Plan to pay for the billed services. You say that the diagnosis code billed is payable. The Plan 
denied your request. The Plan says an appropriate diagnosis code was not billed first. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was billed with primary diagnosis code F09. This diagnosis code as a code 
first note. This code is not permitted to be used as the primary diagnosis code. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service December 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI), pelvis provided on 
September 08, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI), pelvis. You say that you are appealing the 
claim payment denial. 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 magnetic resonance 
imaging (MRI), pelvis provided on September 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and an 
outpatient diagnostic test provided on January 30, 2023, to February 1, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and an outpatient diagnostic 
test . You say that you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and $150 copayment for outpatient diagnostic 
test/performed at outpatient hospital.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and $150 copayment 
for an outpatient diagnostic test. The total allowed amount for the prescription drugs is $3,113.79. You are 
being asked to pay $622.76 ($3,113.79 x 20% = $622.76). The total amount for all services rendered is $772.76 
($622.76 + $150 = $772.76. 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 cost share for Medicare Part B 
prescription drugs and an outpatient diagnostic test provided on January 30, 2023, to February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. 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 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 a crutch substitute (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs, 
outpatient diagnostic tests/X-rays, outpatient diagnostic tests/laboratory services, outpatient rehabilitation 
service, outpatient surgery, and prosthetic devices and related supplies provided on October 21, 2022, to 
October 22, 2022.  
You asked the Plan to waive the cost share for Medicare Part B prescription drugs, X-rays, laboratory services, 
outpatient rehabilitation service, outpatient surgery, and prosthetic devices and related supplies. You say that 
you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs, a $10 copayment for outpatient diagnostic tests/X-rays, a 
$10 copayment for outpatient diagnostic tests/laboratory services, a $40 copayment for outpatient rehabilitation 
service, a $325 copayment for outpatient surgery and 20% coinsurance for prosthetic devices and related 
supplies.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs, a $10 copayment for 
X-rays, a $10 copayment for laboratory services, a $40 copayment for outpatient rehabilitation service, a $325 
copayment for outpatient surgery and 20% coinsurance for prosthetic devices and related supplies. The total 
allowed amount for the prescription drugs is $884.80. You are being asked to pay $176.96 ($884.80 x 20% = 
$176.96). The Total amount for the outpatient surgery is $325 however, you are only being asked to pay $315 
which is less than the required amount. The total allowed amount for the prosthetic devices is $16,739.16. You 
are being asked to pay $3,347.83 ($$16,739.16 x 20% = $3,347.83). The total amount for all services rendered 
is $3,899.79 ($176.96 + $315 + $10 + $10 + $40 + $3,347.83 =$3,899.79). 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 cost share for Medicare Part B prescription drugs, outpatient diagnostic tests/X-rays, outpatient 
diagnostic tests/laboratory services, outpatient rehabilitation service, outpatient surgery, and prosthetic devices 
and related supplies provided on October 21, 2022, to October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apos shoes (T1999). 
 
You asked the Plan to pre-approve Apos shoes. You say that Apos is a covered service by this enrollee's 
insurance for those who report knee and/or back pain or pathology. 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. The 
record shows that the enrollee suffers from back pain. 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 Apos shoes (T1999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to return to prior level of function. The Plan denied your request. The Plan says all services that 
would be provided in the LTACH are being provided in the current acute care setting which is already 
approved.  
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says they do not show that additional home physical therapy visits are needed for 
this to occur.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
Our physician reviewer found clinical documentation shows that the enrollee has mobility impairments 
(beneath functional baseline) and with slow progress, but home exercise program (HEP) has been given. 
Clinical documentation does not explain clinical reasoning for why 12 additional home health physical therapy 
sessions would be medically necessary. The records do not show that skilled therapy services are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the patient's level of function and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), and 
crown - porcelain/ceramic (D2740) provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you followed the Plan's guidelines for out-of-
network services by submitting your bill. You also say that you have been going to the same dentist for years 
and no way want to change. 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 core buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) 
provided on December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent and active before coming to 
the hospital and you want to return to being independent. The Plan denied your request. The Plan says you do 
not meet the criteria 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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care such as 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: 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 will benefit from inpatient rehab 
services that are unable to be met in a lower level of care. The Plan denied your request. The Plan says the 
services the enrollee needs can be provided safely in another setting such as a skilled nursing facility or home 
with home health services.  
 
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 not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on January 24, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary. 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 drug testing provided on 
January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the referring doctor sends the test to the lab. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken.  We looked at the file and Medicare rules. The claim was billed with an outpatient POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 04, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you left after having an 
altercation with a nurse, and should not have to pay. 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 $90 
copayment for in-network emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
in-network emergency care 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 records show you were seen in the emergency room on February 4, 2023. Therefore, 
we decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 04, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current setting.  
 
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 responding to current treatment but not yet stable for 
transfer and should only require short-term additional acute care services that can safely be administered at the 
current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) 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 it is medically necessary for the enrollee to get to 
rehab as soon as possible. The Plan denied your request. The Plan says the enrollee's records do not show that 
they have complex rehabilitation needs. 
 
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 not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.