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

We decided that the Plan does not have to pay for the emergency department visit (99285) provided April 14, 
2020. 
 
You asked the Plan to pay for the emergency hospital services. You say that the records provided should 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the auto insurance 
is the Primary payer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
In this case, the medical records were needed from the provider to determine if the services rendered were 
related to an auto accident. The records show that the Plan had made several attempts to request the needed 
records from the provider with no success.  

The plan is unable to make the proper determination without the records. Based on this information, we 
decided that Medicare rules for coverage of the emergency hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99285) provided April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided from November 22, 
2019, through  
April 13, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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. 
 
 
 
 
 
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided from November 22, 2019, 
through April 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home physician visit (99350) provided October 15, 2019. 
 
You asked the Plan to pay for home physician visit. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the record shows the service 
was provided by an LVN and not a physician, physician's assistant, or Nurse Practitioner. Based on this 
information, we decided that Medicare rules for coverage of home physician visit have not been met. 
Therefore, we decided that the Plan does not have to pay for a home physician visit (99350) provided October 
15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the Fire 
Department on April 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that a neighbor called for this service without 
your approval. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 30, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by the Fire Department on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services with an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that this is the only doctor that can help the member. 
The Plan denied your request. The Plan says this provider is not contracted with the Plan or Medicare and 
furthermore, Medicare does not pay for a service if individuals who are in custody including, but are not 
limited to, individuals who are under arrest, incarcerated, or imprisoned. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-
approve mental health services with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on January 22, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says you must receive your 
care from a network provider. In most cases, care you receive from an out-of-network provider will not be 
covered. If you need medical care that Medicare requires our plan to cover and the providers in our network 
cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain 
authorization from the plan prior to seeking care. In this situation, you will pay the same as you would pay if 
you got the care from a 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 
DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for DME provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
states a urine specimen was collected. Based on this information, we decided that Medicare rules for coverage 
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for recurrent hepatic 
encephalopathy. The patient is not intubated/ventilated. There is no evidence that the patient requires services 
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such 
time no acute services are required.  The patient can then be transferred/discharged to a lower level of care for 
any ongoing LTC needs. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from March 5, 2020, through 
March 10, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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. 
 
 
 
 
 
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
chiropractic services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for chiropractic services provided from March 5, 2020, through 
March 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the clinical information provided 
supports the need for SNF care. The Plan denied your request. The Plan says the enrollee no longer requires 
daily skilled nursing or therapy services, and the continuation of SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received 
oral medications, had stable vital signs, and used oxygen via a nasal cannula. The enrollee received physical 
therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision/stand 
by assist to contact guard assist level with functional mobility, including gait to 125 feet with a rolling walker.  
 
The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity 
of illness or intensity of service criteria for 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
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 rehab will help the enrollee with their recovery and 
restore function. The Plan denied your request. The Plan says the records do not support that the enrollee can 
tolerate or requires 3 hours of daily intense 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 above. 
 
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 physician reviewer found 
that the enrollee is at a supervision level for grooming, and moderate assist for lower body dressing. The 
enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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 the enrollee meets the criteria for admission to an 
IRF, and this level of care is necessary to achieve a safe and sustainable discharge. The Plan denied your 
request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee could receive the care needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an 
IRF. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehab with 
daily physician management. The Plan denied your request. The Plan says the records do not support that the 
enrollee can tolerate or requires 3 hours of daily intense 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 above. 
 
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 physician reviewer found 
the enrollee is at a contact guard assist for sitting up, moderate assist for standing up, and moderate assist for 
walking using a wheeled walker. The enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears unable to 
participate in daily skilled therapy. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, 
as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, other 
than spinal applications (CPT Code E0747). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary for your recovery from knee 
surgery. The Plan denied your request. The Plan says Medicare has determined that it is not covered unless the 
fracture is a long bone fracture that has radiographic evidence of fracture healing for three or more months.  
 
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 DME. Our physician reviewer 
found you did not suffer a long bone fracture. The patella is not considered to be a "long bone" in this 
circumstance. Other imaging studies have shown no fractures of any long bones. Your surgery was not 
otherwise for the fusion of a joint other than in the spine and you are not noted to have a congenital 
pseudarthrosis.  Therefore, the criteria for coverage of an electrical osteogenesis stimulator would not have 
been met. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve osteogenesis stimulator, electrical, non-invasive, other than spinal applications (CPT Code 
E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on December 18, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says e Delivery Ticket submitted did not include the carrier's tracking number, nor did the 
Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the 
Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be 
verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.  
 
 
 
 
 
 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, 
L2397) provided to the enrollee on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99443) provided May 14, 2020. 
 
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this code is not recognized by Medicare. A correct claim is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, this code is not recognized 
by OPPS. Based on this information, we decided that Medicare rules for coverage of the physician services 
have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99443) 
provided May 14, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
This type of service is not considered skilled. It is considered custodial care. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve attendant services for the enrollee.