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

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on May 17, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim was received past the 
allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital services was not filed until July 20, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital services provided on May 17, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray interpretation provided on August 7, 2020. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that this should be paid as it was 
medically necessary. The Plan denied your request. The Plan says that this service was billed on the same day 
as the services described by 322555. The coding rules says that the x-ray taken to determine the adequacy of 
the procedure is included in payment for the procedure. As such, this cannot be separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that PTP edits can only be applied to the services of 
the same physician on the same date of service. 
 
In this case, the physician billing for this chest x-ray interpretation is not the same physician that performed the 
services described by 32555. The documentation shows that this x-ray was not provided immediately following 
the procedure, but at least one hour later. As such, it cannot be confirmed that this would be included in 
payment for the procedure. We find that this denial is not supported. Therefore, we decided that the Plan has to 
pay for the chest x-ray interpretation provided on August 7, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mild obstructive sleep 
apnea and a respiratory event index (REI) of 12. For patients with REI of less than 14, the Medicare rules 
require either symptoms or specific comorbidities to qualify for CPAP. The enrollee does not meet the criteria; 
therefore, the CPAP trial is not reasonable or medically necessary. 
 
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 a continuous positive airway pressure (CPAP) device trial.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested sleep study. 
 
You asked the Plan to pre-approve the sleep study. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested sleep study.
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. The Plan denied your request. The Plan says the 
enrollee is receiving inpatient acute care, and does not require transfer. 
 
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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oxygen supplementation, ventilator management, tracheostomy care, nebulizer treatments,  
intravenous antibiotics, sacral wound care, surveillance laboratory studies, tube feedings, and therapy services. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Acetaminophen-Codeine tablet. 
 
You asked the Plan to pre-approve Acetaminophen-Codeine. You say that the service requested is medically 
necessary. The Plan denied your request. The Plan says this is not a medical necessity denial. This drug is not 
covered for your condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Acetaminophen-
Codeine tablet.  
 
Benefits for Acetaminophen-Codeine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for rhabdomyolysis, 
hyponatremia and delirium tremens. The enrollee's medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 6, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the provider's office advised that the service was 
denied because periodontal deep cleaning is not a covered service. You say that the deep cleaning costs less 
than the regular cleaning that you received. You also say that this should be a good thing. The Plan denied your 
request. The Plan says periodontal maintenance is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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, periodontal maintenance is not a preventive dental 
service. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on August 6, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Arthrodesis of the sacroiliac joint (27279). 
 
You asked the Plan to pre-approve this service. You say that Arthrodesis of the sacroiliac joint is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that this procedure is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Arthodesis of the sacroiliac joint is medically 
necessary if all Medicare criteria have been met. 
 
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 this service. Our reviewer says that this 
procedure is medically necessary for the enrollee. Our physician reviewer found that the enrollee has a 
diagnosis of Sacroiliitis, not elsewhere classified. The enrollee has ongoing low back pain. The enrollee has 
trialed multiple medications, and underwent extensive physical therapy which included bracing. The enrollee 
has had multiple epidural injections and sacroiliac joint injections with no relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve Arthrodesis of the sacroiliac joint (27279).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided from January 14, 
2020, to May 20, 2020.  
 
You asked the Plan to pay for these services. You say that this care was medically necessary. The Plan denied 
your request. The Plan says the providers are not Medicare eligible providers. 
 
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. These 
services were rendered by providers who have opted out of the Medicare program. Therefore, we decided that 
the Plan does not have to pay for outpatient mental health care provided from January 14, 2020, to May 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 22, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you only received test results and do not feel that it warranted a copayment. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 a $40 
copayment for each specialist visit.  
 
 
The medical records show that you received a specialist visit on July 22, 2020. Therefore, you are responsible 
to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this procedure is not covered for treatment of chronic knee pain. 
 
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 nerve block procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found Genicular nerve blocks and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
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 nerve block procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Genicular nerve block (64454).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 2, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on January 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs 24/7 pulmonary 
monitoring, and frequent checks of mental status and signs of dehydration. This level of care is needed to 
prevent the need for hospitalization. The Plan denied your request. The Plan says there is no documented need 
for daily skilled care. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was found to have 
COVID-19 on 12/6/2020 and was admitted for SNF care from an assisted living facility for isolation. The 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is functioning at her baseline.  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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you have had ambulance service in the past 
and were not charged this amount. 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 March 17, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250) provided on September 1, 2020. 
 
You asked the Plan to pay for the fundus photography. You say that you were not aware that you would be 
charged this amount. The Plan denied your request. The Plan says the claim processed correctly, and no 
reimbursement is due. 
 
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. 
 
We looked at the file and the Plan's rules. Though the Plan offers a vision benefit in excess of Medicare 
coverage, the requested service is not among those covered under this benefit. Based on this information, we 
 
 
decided that the Plan's rules for coverage of the fundus photography have not been met. Therefore, we decided 
that the Plan does not have to pay for the fundus photography with interpretation and report (92250) provided 
on September 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on November 23, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice status at the time of service this claim should be submitted 
to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on November 23, 2019.