Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network (OON) provider on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 chiropractic care provided on September 21, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy provided on March 01, 2022, to July 
27, 2022. 
 
You asked the Plan to pay for home infusion therapy. You say that this service is supported in the records. 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 infusion therapy 
provided on March 01, 2022, to July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 3, 2022, 
through April 8, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9, Sepsis. 
 
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 primary diagnosis code A41.9-sepsis, unspecified 
organism. 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 documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the member presented with an altered mental status. The member 
was found to have hyperglycemia, mild electrolyte derangements and a urinary tract infection. Twenty-four 
hours later, the member was noted to be completely oriented, but with a weird affect. The treatment continued 
for the urinary tract infection, mild pulmonary edema, and insulin non-compliance. There is no evidence that 
the member had hemodynamic instability or organ failure due to the urinary tract infection. As such, diagnosis 
code A41.9-sepsis, unspecified organism is not the appropriate primary diagnosis code.  
 
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 on April 3, 2022, through April 8, 2022, and billed with diagnosis code 
A41.9.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 13, 2022 to 
January 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 13, 2022 to 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
an out-of-network (OON) provider on June 29, 2022. 
 
You asked the Plan to pay 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 the service was rendered by an out-of-network 
provider, without prior authorization. 
 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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no 
exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have 
to pay for the chiropractic manipulative treatment (98940) rendered by an out-of-network (OON) provider on 
June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of residual tooth roots (D7250 x4, D7210 
x2), extraction erupted tooth (D7140x5), surgical placement implant (D6010 x4), bone graft (D6104 x4) and behavior management by report (D9920) provided on June 7, 2022. 
 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the surgical removal of residual tooth roots (D7250 x4, D7210 x2), and 
extraction erupted tooth (D7140x5), has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for surgical removal of residual tooth roots (D7250 x4, D7210 x2), extraction erupted tooth 
(D7140x5), surgical placement implant (D6010 x4), bone graft (D6104 x4) and behavior management by 
report (D9920) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thrombectomy and related services provided on August 19, 
2022. 
 
You asked the Plan to pay for a thrombectomy and related services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a thrombectomy and 
related services provided on August 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member requires an IRF admission to return to 
prior level of function. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 need rehabilitation to regain mobility to perform 
daily activities. The Plan denied your request. The Plan says the member does not meet the Medicare criteria 
for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on  
December 8, 2022. 
 
You asked the Plan to pay 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 the dental service was received from an 
unassigned, out-of-network dentist and is not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
  
 
The record shows you received the dental service from an unassigned, out-of-network dentist. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the service provided is not covered under this benefit 
when received from an unassigned, out-of-network dental provider. Therefore, we decided that the Plan does 
not have to pay for the periodontal maintenance (D4910) provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and  
supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM monitor and supplies are a 
medical necessity. The Plan denied your request. The Plan says that the details received from your doctor don't 
meet Medicare guidelines that show a medical reason you need a Freestyle Libre continuous glucose monitor 
system and standard supply allowance for this device. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the enrollee meets criteria as submitted for CGM coverage. Our physician reviewer found the insulin 
is being adjusted according to the submitted medical records in the additional information, based on blood 
glucose levels. 
 
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 CGM and supplies have been met. Therefore, we decided that the Plan has 
to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and  supplies.  
 
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 pay for the medical eye examination and the ophthalmic diagnostic 
imaging provided on December 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye examination and the ophthalmic diagnostic imaging. You say 
that you are in-network. The Plan denied your request. The Plan says the provider is out-of-network, and the 
enrollee was referred by an out-of-network provider. 
 
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 did not pre-approve the 
medical eye examination and ophthalmic diagnostic imaging. 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 the medical 
eye examination and the ophthalmic diagnostic imaging provided on December 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy is medically necessary to 
alleviate the pain in your neck. The Plan denied your request. The Plan says Medicare Guidelines state that 
massage therapy provided by a licensed massage therapist is not covered. Massage therapy is only covered 
under specific conditions, which are when provided by a physical therapist within a physical therapy program. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care provided on February 7, 2022, to 
February 8, 2022. 
 
You asked the Plan to pre-approve custodial care. You say that you need more time with custodial care. The 
Plan denied your request. The Plan says custodial care/personal care are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial care 
provided on February 7, 2022, to February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
January 11, 2023. 
 
You asked the Plan to pay for dental services. You say that you had no idea the requested treatment was not 
covered, the provider was unaware also. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
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. This benefit includes only 
those items and services specifically listed in your Plan contract. Fluoride varnish (D1206) is not covered under 
the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1206 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride varnish (D1206) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
an out-of-network (OON) provider on June 27, 2022. 
 
You asked the Plan to pay 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 this service was rendered by an out-of-
network provider, without prior authorization. 
 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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no 
exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have 
to pay for the chiropractic manipulative treatment (98940) rendered by an out-of-network (OON) provider on 
June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
an out-of-network (OON) provider on October 28, 2022. 
 
You asked the Plan to pay 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 the service was rendered by an out-of-network 
provider, without prior authorization. 
  
 
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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no 
exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have 
to pay for the chiropractic manipulative treatment (98941) rendered by an out-of-network (OON) provider on 
October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on December 15, 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 services denied correctly as they do not fall 
within your dental 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 pay for a dental 
crown (D2740) provided on December 15, 2022.