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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you are still in pain after your previous injection. 
The Plan denied your request. The Plan says an epidural steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that you have a history of low back 
pain with radiation to the left lateral calf which began after you fell on March 23, 2023. Also, your pain has 
gotten progressively worse over the past two months. You have also been treated with medications including 
opiates and has undergone a L5-S1 transforaminal epidural steroid injection on February 22, 2023. That 
injection was reported to have given you 100 % pain relief for four days. Therefore, you do not meet the LCD 
coverage criteria for a repeat epidural steroid injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0299, Q5001) provided on 
November 8, 2022, to December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 November 8, 2022. The NOA was not received by the Plan until December 
12, 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 (G0151, 
G0299, Q5001) provided on November 8, 2022, to December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, Q5001) provided on 
November 19, 2022, to November 29, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. 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 November 19, 2022. The NOA was not received by the Plan until January 
13, 2023. 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 (G0151, 
Q5001) provided on November 19, 2022, to November 29, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for date of service March 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that authorization was received for these services. 
The Plan denied your request. The Plan says that the type of bill with the last digit of 3 is invalid for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
The claim at issue was submitted with type of bill 032A, which is valid for payment. Based on this information, 
we decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that 
the Plan has to pay for the home health care billed for date of service March 6, 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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate.  The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
18, 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 for 
your complex medical needs. The Plan denied your request. The Plan says you do not require complex medical 
care.  
 
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 record indicates that you have ongoing acute medical issues and still require acute 
care services. You continue to receive acute care services, and these have not been denied. The medical record 
does not indicate that you require services that you are not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and debridement provided on December 21, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a home visit and debridement. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 a home visit and debridement provided on 
December 21, 2022, by an out-of-network (OON) provider.
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 are requesting reconsideration for the denial of 
an IRF admission. You say you feel the enrollee needs that level of care. The Plan denied your request. The 
Plan says the enrollee does not meet the medical necessity 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech generating device to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve speech generating device. You say that the services should be covered. The 
Plan denied your request. The Plan says this 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 
speech generating device 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 waive the copayment for extractions (D7150) provided on February 
10, 2023. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 have been asked to pay $185 copayment for 5 extractions. This item/service falls within the dental 
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 extractions (D7150) 
provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination and the not medically necessary service 
provided on January 18, 2023. 
 
You asked the Plan to pay for the vision services. You say that you paid out-of-pocket for a non-medical 
covered service. You say you were unhappy with the denial. The Plan denied your request. The Plan says the 
service was not a covered benefit. 
 
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 provided 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 eye examination and the not medically necessary service 
provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve endosteal implants (D6010 x 2). We decided that the Plan does 
not have to pre-approve interim complete denture mandibular (D5811), implant/abutment supported removable 
denture (D6111), radiographic/surgical implant index (D6190) and removal of impacted tooth (D7230, D7240).  
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because you 
need these dental procedures. The Plan says that these services are not covered under the Plan's dental benefits. 
 
We decided that the Plan has to pre-approve endosteal implants (D6010 x 2).  
 
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. Endosteal implants are covered benefits listed on page 130 of the 2023 EOC. No 
records were provided showing the enrollee has exhausted this benefit or that these procedures are not 
medically necessary. Therefore, we decided that the Plan has to pre-approve endosteal implants (D6010 x 2).  
 
We also decided that the Plan does not have to pre-approve interim complete denture mandibular 
(D5811), implant/abutment supported removable denture (D6111), radiographic/surgical implant index 
(D6190) and removal of impacted tooth (D7230, D7240).. 
 
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. Additionally, D6111 is a covered benefit but this benefit will be 
exhausted on the approval of two endosteal implants. Therefore, we decided that the Plan does not have to pre-
approve interim complete denture mandibular (D5811), implant/abutment supported removable denture 
(D6111), radiographic/surgical implant index (D6190) and removal of impacted tooth (D7230, D7240). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership (S9970) purchased on 
January 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable 
benefit for this service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the Plans contract states that the plan reimburses you up to $150 per 
calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan issued 
reimbursement to you on April 15, 2022 and June 3, 2022 for the total amount of $150 for the gym 
membership purchased for the 2022 calendar year. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to issue reimbursement for the gym membership 
(S9970) purchased on January 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 2, 2023, to January 5, 
2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee had chest discomfort and 
palpitations. The Plan denied your request. The Plan says that an inpatient admission 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found based on the complexity and severity of the clinical situation at the time of admission, it was 
expected that the enrollee would require hospital services that would likely cross 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 2, 2023, to January 5, 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: 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 are a fall risk, and there is no one to take care of 
you if you fall. You say you need rehabilitation to get stronger, and you need more time to heal. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve an interlaminar/interspinous process . You say that the enrollee is in a lot of 
pain. The Plan denied your request. The Plan says this procedure is not covered. 
 
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 an interlaminar/interspinous process. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an interspinous process stabilization devices are experimental, and 
more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an interlaminar/interspinous process have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device.