Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 5, 
2023, to March 5, 2023. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 pay for 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 the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a 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 pay for skilled nursing facility (SNF) care provided from February 5, 2023, to March 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement procedure to be provided by 
the requested out-of-network network provider as an in-network benefit level exception.  
 
You asked the Plan to pre-approve a total knee replacement procedure to be provided by the requested 
out-of-network provider as an in-network benefit level exception. You say that you could not get an evaluation 
appointment with an in-network provider timely and your condition is deteriorating. The Plan denied your 
request. The Plan says there are contracted providers who may render similar services within a reasonable 
timeframe. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you can choose to receive care from out-of-network providers. If you use an out-of-network 
provider, your share of the cost for your covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services as an in-network benefit level exception. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement procedure to be provided by the requested out-of-
network provider as an in-network benefit level exception.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic consultation (D9310), an extraction 
(D7210), and a bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve D9310, D7210, and D7953. You say that this dental work is medically 
necessary. The Plan denied your request. The Plan says this dental work are not covered 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. 
 
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 pre-approve a 
diagnostic consultation (D9310), an extraction (D7210), and a bone replacement graft for ridge preservation 
(D7953).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more towards medical services provided out-of-country on 
November 24, 2022, to November 25, 2022. 
 
You asked the Plan to pay more towards the out-of-country medical services. You say that you are in debt to a 
family member who paid for all the medical expenses using their credit card. You say that it is physically and 
financially difficult for you to pay that amount back, as you do not work.  The Plan denied your request. The 
Plan says you were reimbursed at the Medicare rates in the amount of $6,663.25. The difference of the total 
charges that you paid, and the Medicare rate is not reimbursable.  
 
The Plan must follow Medicare rules. Medicare rules say that they do not pay for most services provided 
outside of the United States. However, the Plan offers a supplemental benefit that exceeds Medicare coverage. 
The Plan's rules for coverage of worldwide emergency care state that the coverage is limited to Original 
Medicare reimbursement rates.   
We looked at the file and Medicare rules. Based on this information, we decided that Plans rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay more towards medical services 
provided out-of-country on November 24, 2022, to November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
right knee pain. She has been treated with medication and Hyalgan injections with no improvement. The use of 
genicular RFA is considered experimental in nature and is not medically necessary at this time. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your needs continued physical therapy. The Plan 
denied your request. The Plan says that you do not meet 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your medical records overall significantly complies with the various documentation requirements for IRF 
admission. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 1, 2022, 
to November 7, 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 records support the billed DRG. The Plan denied your request. The Plan says diagnosis code E43 
(Unspecified severe protein-calorie malnutrition) is not supported by the medical records.  
 
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 diagnosis code E43 (Unspecified severe protein-
calorie malnutrition). 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 medical records to not support the diagnosis 
billed. Our physician reviewer found that the enrollee, who is homeless, with history of Multiple Sclerosis with 
generalized weakness and fatigue. The admission was for Multiple Sclerosis exacerbation. No weight loss is 
noted in medical record. The enrollee was noted to have a body mass index (BMI) of 19.99 during the hospital 
stay. The enrollee was treated with intravenous (IV) steroids along with physical therapy and discharged. In 
this case, there was no clinical or laboratory evidence of protein calorie malnutrition. The review has 
determined that the documentation does not support the diagnosis code E43 (Unspecified severe protein-calorie 
malnutrition). 
 
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 from November 1, 2022, to November 7, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport, and ground mileage to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the ambulance services and ground mileage. You say that you respectfully 
request that you reconsider your decision and allow payment for the services provided. The Plan denied your 
request. The Plan says medically necessary care is available in 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 
ambulance service, basic life support, non-emergency transport, and ground mileage to be provided by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under pressure, full body 
chamber, per 30-minute interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen 
therapy, per session (99183x20). 
 
You asked the Plan to pre-approve HBO therapy. You say that the requested HBO therapy is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records show the enrollee has an 
ulcer secondary to chronic peripheral vascular insufficiency, which is not a covered indication for the requested 
treatment. 
 
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 HBO therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has extremity venous ulcer secondary to chronic peripheral 
vascular insufficiency. The noted indication is not one enumerated under the rules for which coverage is 
available. The elements of the coverage criteria are not satisfied. The requested service is not 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) under pressure, full body chamber, per 30-minute interval 
(G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183x20).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) and accessories (A7035, 
E0562). 
 
 
 You asked the Plan to pre-approve a home ventilator and accessories. You say that if the enrollee does not 
receive a home ventilator, she will have increased breathing issues, as her respiratory muscle will weaken. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in multiple modes 
including BiPAP that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator and accessories. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
multiple sclerosis (MS) with neuromuscular disease. Although this may be progressive, there is no 
documentation, other than, reducing superior vena cava (SVC). This may or may not support the escalation of 
therapy, but data is lacking. She requires further therapy and/or studies to confirm need for BIPAP therapy.   
Hence, BIPAP is not indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator (E0466) and accessories (A7035, E0562).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (coagulation factor V) (e.g., hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration because the 
provider believes they need to increase the enrollee's blood thinners but needs to verify with this test. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for these genes for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for 
pregnant patients.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the requested genetic testing is non-covered except 
for pregnant patients. Therefore, we decided that the Plan does not have to pre-approve F5 (coagulation factor 
V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found during the encounter of July 9, 2023, the 
patient had neck pain but negative neuro exam. Plain films show degenerative changes. There is no red flag to 
mandate MRI prior to 6 weeks of physical therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on September 13, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that this provider is covered under the patient's 
benefit plan. The Plan denied your request. The Plan says virtual care is not covered out-of-network. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network.  
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) are not covered out-of-network. Based on this information, we decided 
that the Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the 
Plan does not have to pay for telehealth services provided on September 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 8, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says in order for the facility to receive reimbursement for a 
Medicare member, the facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 30 additional transportation rides. 
 
You asked the Plan to pre-approve the 30 additional transportation rides.. You say that you still need additional 
rides to your physical therapy (PT) appointments. You say your quality of life may be compromised if you 
cannot continue to progress with your PT. The Plan denied your request. The Plan says the benefit has been 
exhausted.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the 30 additional transportation rides.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 physical therapy visits to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the physical therapy visits. The Plan denied your request. The Plan says that 
the physical therapy visits are available in 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 
30 physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography, the routine exam, the frames, the 
oversized lens, and the single vision lens provided on April 22, 2023. 
 
You asked the Plan to pay for the vision services. You say that the provider never confirmed that you did not 
have out-of-network benefits. The Plan denied your request. The Plan says the services were obtained from an 
out-of-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the fundus photography, the routine exam, the frames, the 
oversized lens, and the single vision lens provided on April 22, 2023.