Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for subsequent nursing care provided on 
December 19, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay the in-network rate for the subsequent nursing care. You say that the enrollee was in 
a nursing home, and the claim should be processed as in-network. The Plan denied your request. The Plan says 
the services were not urgent or emergent, and the claim has been paid according to the enrollee's benefits. 
 
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 the in-network rate 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 the in-network rate for these 
items/services. Therefore, we decided that the Plan does not have to pay the in-network rate for subsequent 
nursing care provided on December 19, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the thoracic spine 
provided on January 15, 2023. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI) of the thoracic spine. You say that the 
services are payable per Medicare guidelines. 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 magnetic resonance 
imaging (MRI) of the thoracic spine provided on January 15, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 14, 2022, 
through October 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was transferred from the behavioral unit to the emergency department (ED ) on  
October 14, 2022 with a urinary tract infection and to rule out sepsis. She was treated with intravenous fluids 
and antibiotics. Her condition stabilized and improved and she was discharged to a skilled nursing facility on 
October 18, 2022. The review has determined that the record showed that at the time of the inpatient admission 
the admitting physician reasonably expected that the enrollees necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 14, 2022, through October 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve acupuncture. You say that you have been seeing this provider since 2016 
and are more comfortable with them. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and you can be treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 20, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you were given medication that cannot be 
bought over the counter. The Plan denied your request. The Plan says that self-administered drugs do not fall 
under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the family is requesting the enrollee to go to the 
acute inpatient rehabilitation facility. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femoral fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says that you have exhausted 100 days of SNF 
care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 16, 2022, to 
May 11, 2023. The Plan has covered 100 days of SNF care. 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic images 
(D0230 x 3), extractions, of an erupted tooth or exposed root (D7140 x 2), and the extractions, of an erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) provided on January 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by the enrollees 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 the enrollee received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided 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 
the limited oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic images (D0230 x 3), extractions, of an erupted tooth or exposed 
root (D7140 x 2), and the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth  
(D7210 x 2) provided on January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you do not want to spend your life on 
pain medicine and this procedure would stop the pain. The Plan denied your request. The Plan says the 
Intracept procedure is investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the cause of back pain is not clear. There is no imaging showing only Modic 
changes without facet degenerative joint disease or foraminal stenosis. 
  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 Intracept procedure. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panoramic radiographic image (D0330), a complete 
upper denture (D5110), a complete lower denture (D5120), the surgical placement of the implant body 
(D6010), the custom fabricated abutment (D6057), and root removal (D7130) for tooth #23 and #26 to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need to get new dentures and would 
like for the implants to be covered. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. Also, the surgical placement of the implant 
body, the custom fabricated abutment, and root removal are not covered by the Plan in or out-of-network. 
 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the panoramic radiographic image and the complete upper and lower dentures are 
not covered under this benefit when received from an out-of-network provider. The surgical placement of the 
implant body, the custom fabricated abutment, and root removal are not covered under the Plans dental 
benefit. Therefore, we decided that the Plan does not have to pre-approve a panoramic radiographic image 
(D0330), a complete upper denture (D5110), a complete lower denture (D5120), the surgical placement of the 
implant body (D6010), the custom fabricated abutment (D6057), and root removal (D7130) for tooth #23 and 
#26 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
(D7953) and guided tissue regeneration-resorbable barrier, per site (D4266). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge 
preservation-per site (D7953) and guided tissue regeneration-resorbable barrier, per site (D4266).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
January 17, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were told to go 
to the emergency room to have a second x-ray. 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 outpatient hospital services. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the outpatient hospital 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 
the emergency room services provided on January 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 07, 2022, to 
December 08, 2022. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on December 07, 2022, to December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 07, 2023. 
 
You asked the Plan to pay for home health services. You say that you say that the patient is homebound and is 
confined to his home. 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 home health services 
provided on March 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the submitted medical records support the need for 
IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia and chronic obstructive pulmonary disease exacerbation. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the medical records support a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 28, 2022. 
 
You asked the Plan to pay for office visit. You say that you believe the services are 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 office visit provided on 
November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulette wheelchair transportation (A0100). 
 
You asked the Plan to pre-approve the ambulette wheelchair transportation. You say that the enrollee travels 
with a wheelchair and is unable to transfer independently. You also say that the enrollee needs driver assistance 
in and out of buildings and into the dialysis unit three times per week. The Plan denied your request. The Plan 
says per Medicare coverage guidelines, ambulette transportation is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve ambulette wheelchair transportation (A0100).