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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 23, 
2022, to March 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing with supporting 
medical records. The Plan denied your request. The Plan says inpatient level of care 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found the enrollee presented to the emergency department with dizziness and high blood 
pressure which began at a urologist's office appointment. Workup was negative or unremarkable. The enrollee 
reported no loss of consciousness and symptoms had already resolved. At the time of admission, there was no 
expectation that the enrollee would require hospital services that would likely span at least 2 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 23, 2022, to March 28, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing (0339U) provided on January 3, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the SelectMDx testing by a contract provider. The file does not show that the plan 
provided notice that the SelectMDx testing would not be covered. Under Medicare rules, this means the 
SelectMDx testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
SelectMDx testing (0339U) provided on January 3, 2023.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx testing (0239U) provided on May 31, 
2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx testing. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says that this testing is not covered. 
 
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. In this case medical records are needed to review the medical necessity of this 
testing. Only the lab report was provided. There is no evidence that the Plan attempted to obtain the medical 
records. Without this information we are unable to verify that the claim was denied correctly. Therefore, we 
decided that the Plan has to pay for the FoundationOne Liquid CDx testing (0239U) provided on May 31, 
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: 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 admission is a medical necessity. The Plan denied 
your request. The Plan says the requested service is not medically necessary, as Medicare criteria have not been 
met due to not requiring intensive levels of therapy. 
 
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 hypoxemia, syncope, and pneumonitis. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each mental health visit provided on 
January 05, 2023, to February 09, 2023. 
 
You asked the Plan to reduce the coinsurance for each mental health visit. You say that you did not know the 
provider was out-of-network. 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 40% 
coinsurance for out-of-network outpatient mental health care. 
 
You have been asked to pay 40% coinsurance for each mental health visit. This item/service falls within the 
out-of-network outpatient mental health 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 coinsurance amount is $46.30 for each visit ($115.76 allowed amount x 
40% coinsurance = $46.30). Therefore, we decided that the Plan does not have to reduce the coinsurance for 
each mental health visit provided on January 05, 2023, to February 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from January 2, 2023, 
through January 3, 2023. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says no medical records were received. The Plan cannot determine how the 
enrollee came to the servicing provider, whether the services were performed as billed, or whether the services 
were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient services have been met. 
There are no medical records within the casefile. Without the requested clinical information, we are unable to 
determine if the requested services are medically necessary. Therefore, we decided that the Plan does not have 
to pay for the inpatient services provided from January 2, 2023, through January 3, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the spinal injection provided on December 21, 2022. 
We also decided that the Plan does not have to fully waive the coinsurance for the spinal injection provided on 
December 21, 2022.  
 You asked the Plan to waive the coinsurance the spinal injection provided. You say that you were not able to 
get the second injection because the first injection did not work. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the spinal injection.  
 
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 20% 
coinsurance for Medicare Part B drugs and drug administration.  
 
The Plan says you must pay $295.24, or 21.4% of the $1,379.33 allowed amount shown on the claim provided 
for the drug administration. Based on the Plan contract, however, you cannot be asked to pay more than a 20% 
coinsurance, or $275.87, for the drug administration ($1,379.33 allowed amount x 20% coinsurance = 
$275.87). Therefore, we decided that the Plan has to reduce the coinsurance the spinal injection provided on 
December 21, 2022.  
 
We also decided that the Plan does not have to fully waive the coinsurance for the spinal injection. 
 
You are responsible for 20% coinsurance of the allowed amount for Part B drugs and administration. This 
item/service falls within the Medicare Part B drugs benefit category. This cost sharing is a contractual 
obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
fully waive the coinsurance for the drug administration provided on December 21, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency clinic services provided on December 1, 
2022. 
 
You asked the Plan to pay for the emergency clinic services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency clinic services provided 
on December 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemodialysis services (90935) provided from June 23, 
2022, to July 26, 2022. 
 
You asked the Plan to pay for the hemodialysis services. You say that you required dialysis during a family 
health emergency while you were out of the country. You also say that you were advised that you could be 
reimbursed for your dialysis treatments out of the country. The Plan denied your request. The Plan says chronic 
dialysis is not covered under Worldwide coverage for urgent and emergency services. 
 
The Plan must follow Medicare rules. Medicare rules say that services provided outside of the United States are 
excluded from coverage except in certain specified circumstances. 
 
We looked at the file and Medicare rules. The contract clearly states that pre-scheduled, pre-planned treatments 
(including chronic dialysis) for any ongoing chronic conditions and/or elective procedures are not covered 
outide of the United States. Based on this information, we decided that Medicare rules for coverage of the 
hemodialysis services have not been met. Therefore, we decided that the Plan does not have to pay for the 
hemodialysis services (90935) provided from June 23, 2022, to July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  IS-500 Inogen One G5 System (E1399). 
 
You asked the Plan to pay for the IS-500 Inogen One G5 System. You say that you needed this item. The Plan 
denied your request. The Plan says you already have a similar item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were renting an oxygen concentrator at the time the IS-500 Inogen One G5 System was 
received. This device serves the same purpose as IS-500 Inogen One G5 System. The purchase of oxygen equipment is not covered. Therefore, we decided that the Plan does not have to pay for  IS-500 Inogen One G5 
System (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tub stool or bench, a bath rub wall rail, and sales tax 
provided on October 6, 2022.  
 
You asked the Plan to pay for a tub stool or bench, a bath rub wall rail, and sales tax. You say that you could 
not bear any weight on both of your feet and the items were medically necessary. The Plan denied your request. 
The Plan says this item is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that tub stools are not covered because they are not 
primarily medical in nature. Medicare rules also say that Medicare does not make separate payment for sales 
tax. The rules say that no Medicare payment may be made to a beneficiary for items or services provided 
directly by a supplier or provider who has opted out of the program except in cases involving emergencies or 
urgently needed care. 
 
While a tub stool and bath rub wall rail may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Records also indicate the items were received by a provider who is not a Medicare 
certified supplier, also Medicare does not make separate payment for the requested sales tax reimbursement. 
Therefore, we decided that the Plan does not have to pay for a tub stool or bench, a bath rub wall rail, and sales 
tax provided on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cast crown on tooth # 9 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the tooth has already been filled 6 times and is not 
strong enough to retain filling material. The tooth has become weaker and weaker with each fill. The Plan 
denied your request. The Plan says these records do not indicate the criteria was met. 
 
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 Plan covers crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation indicates that there is not significant coronal breakdown of tooth #9 from caries or fracture to warrant a crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a cast crown on tooth # 9 (D2740).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on September 9, 2022. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the NOA was not received timely. 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 start of care date is September 9, 2022. The NOA was not received by the Plan until October 
19, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services on 
September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98942) and an 
office visit (99204). 
 
You asked the Plan to pre-approve these 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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have foot pain in the setting of rheumatoid arthritis. The records provided do not document 
the presence of a subluxation of the spine either by physical examination or radiographic images. The elements 
of the coverage criteria are not satisfied. The requested services are not recommended. Additionally, a 
chiropractic office visit is not a covered benefit by Medicare or the Plan.  
 
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 chiropractic manipulative treatments (98942) and an office visit (99204).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound therapy (97035), therapeutic exercises (97110), 
neuromuscular re-education (97112), manual therapy (97140), and electrical stimulation (G0283) provided on 
September 26, 2022, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for ultrasound therapy, therapeutic exercises, neuromuscular re-education, manual 
therapy, and electrical stimulation. You say that the services were medically necessary. The Plan denied your 
request. The Plan says the health plan requires utilization of network providers when possible and available and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented. 
 
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 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 ultrasound therapy (97035), therapeutic exercises 
(97110), neuromuscular re-education (97112), manual therapy (97140), and electrical stimulation (G0283) 
provided on September 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the requested inserts are medically necessary for 
the enrollee's health. 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 provided do not support that the requested orthotics are needed as an integral part of brace or that the 
enrollee is a diabetic, also a standard written order should be submitted before a claim is. Although orthotics 
may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the 
enrollees condition.  Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on September 12, 2022. 
 
You asked the Plan to pay for the ambulance services and ground mileage. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 14, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, emergency transport and ground mileage provided on September 12, 2022.