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

 
We decided that the Plan does not have to pay more for the oral exam (D0120), prophylaxis (D1110), and 
bitewing x-rays (D0274) provided. 
 
You asked the Plan to pay more for the dental services. You say that you contacted the Plan to make sure you 
could have procedure and cleaning done for free. You say that the x-rays were supposed to be free too. You say 
that this is the only provider that has always been able to help you due to your temporomandibular joint 
disorder (TMJ). You also say that you cannot afford to pay this bill due to the pandemic. The Plan denied your 
request. The Plan says the provider in this case is out of network. The Plan says that there is a 50% coinsurance 
for the dental services that you received out of network. The Plan says that you are responsible for the 
difference between the in network fee schedule (INFS) and dentists' charged fees when visiting an out of 
network dentist. The Plan also says there is no record of you contacting the Plan prior to the date of service to 
verify benefits or provider eligibility. 
 
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 cost share amount may be higher 
for services that you receive out of network. The Evidence of Coverage clearly shows you pay a 50% 
coinsurance for dental services that you receive out of network. Therefore, we decided that the Plan does not 
have to pay more for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from July 23, 2020, to 
August 22, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from July 23, 2020, to August 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) and 
unspecified preventative procedure (D1999) provided. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents and unspecified preventative 
procedure. You say that you would like these services reprocessed and approved for payment. The Plan denied 
your request. The Plan says these services are not covered under your supplemental benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents (D4381) and unspecified preventative procedure (D1999) provided.
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. The Plan denied your request. The Plan says a 
LTACH admission 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 that the enrollee was admitted to the current acute care hospital with dehydration, 
pulmonary hemorrhage from vasculitis, acute kidney injury, and acute respiratory failure due to worsening 
chronic lung disease due to aspergillus. She required oxygen, BiPAP, hemodialysis, steroids, antibiotics, and 
plasma exchange. Kidney function is stabilizing and her breathing status is improving to where she no longer 
requires BiPAP. The records show that the enrollee requires oxygen weaning, which can be safely be 
completed in the current setting. The enrollee does not require services at the LTACH that are not already 
available at the current setting. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current setting. Therefore, this request for LTACH services will be 
considered not medically necessary. There is no notable improvement in care from transferring to LTACH over 
currently available services. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injections of upper or middle spine facet joint using 
imaging guidance to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there are network provider available for these services. 
 
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 
injections of upper or middle spine facet joint using imaging guidance to be provided 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your 
weakness and poor endurance. Our physician reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20610) provided on January 19, 2020. 
 
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the service 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20610 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance.  
 
We asked our coder 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 arthrocentesis. Our reviewer says that CPT code 20610 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records 
provided indicates that the arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, 
knee, subacromial bursa); without ultrasound guidance was performed on January 22, 2020, therefore this 
service cannot be verified as performed on January 19, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the arthrocentesis have not been met. Therefore, we decided that the Plan does 
not have to pay for arthrocentesis (20610) provided on January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a concentrator and portable oxygen machine. 
 
You asked the Plan to pre-approve the concentrator and portable oxygen machine. You say that you would like 
reconsideration because you were advised that you need to use your concentrator every night due to your levels 
going down at night. The Plan denied your request. The Plan says the documentation does not support home 
oxygen use. 
 
The Plan follows Medicare rules. Medicare rules say that if all of the coverage conditions are not met, the 
oxygen therapy will be denied as not reasonable and necessary.  
 
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 concentrator and portable oxygen 
machine. Our reviewer says that coverage criteria have not been met for home oxygen. Our physician reviewer 
found the medical records show only resting, awake oxygen saturations of 93% and 95% breathing room air, 
which do not meet criteria for supplemental oxygen.  There are no overnight oximetry data or measurements 
during activity. 
 
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 concentrator and portable oxygen machine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a concentrator and portable oxygen machine.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee 
has lumbar spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the spacer is experimental. More research is needed to show safety and efficacy. Open laminectomy 
is the standard evidence-based treatment for this condition. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 11, 2020 to April 9, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says in the claim, the service date is March 21, 2020 
and the first visit was March 11, 2020. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, there is a 
discrepancy regarding the date of the first covered visit. The record indicates that the incorrect date of service 
has been billed. Therefore, we decided that the Plan does not have to pay for the home health services provided 
to the enrollee from March 11, 2020 to April 9, 2020.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to LTACH. 
 
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. Long term 
acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical 
services that are materially different than those of short term acute care hospitals. You are receiving acute 
hospital care, and acute care services have not been denied. The documentation does not support that you 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 
services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric care provided from August 27, 
2020, through August 31, 2020. 
 
You asked the Plan to pay for the continued inpatient care. You say that the enrollee required a five-day stay in 
order to ensure she was mentally stable for release. The Plan denied your request. The Plan says after one day 
of treatment, the enrollee could have been discharged to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient care. Our reviewer 
says that the inpatient mental health care provided is not shown to be medically reasonable and necessary. Our 
physician reviewer found this 54-year-old female was involuntarily admitted to the acute inpatient psychiatric 
hospitalization on August 26, 2020 with Schizoaffective Disorder Bipolar Type. This patient presented the 
emergency department with suicidal ideation and a plan to use a knife as well as homicidal ideation toward her 
payee. This patient was not sleeping and had no place to live. The patient did not act on her suicidal ideation 
and had no knife access. She was found to be hyperverbal with grandiosity and odd beliefs. The patient does 
have a history of suicide attempts in the past.  
 
Based upon review the records provided it was not expected this enrollee would improve in a reasonable period 
of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any 
auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats 
to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as she did not have 
dangerousness to self or others but was compliant with her treatment. The health plan?s denial of continued 
inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health 
treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory 
or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the patients condition or for the purpose of diagnosis beyond the date in question. 
 
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 continued inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient psychiatric care provided from August 27, 2020, through August 31, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Mediven Butler Stocking Application Aid. 
 
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 primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Mediven Butler Stocking Application Aid.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on May 
31, 2020 through June 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was billed without the required therapy modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97167 is "Occupational therapy evaluation, high 
complexity." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
Medicare Claims Processing Manual states therapy codes must be submitted with the appropriate modifier to 
be considered for reimbursement.  Occupational Therapy code 97167 must be submitted with modifier GO. 
The provider did not bill CPT 97167 services from May 31,2020 through June 4, 2020 with a GO modifier, 
therefore these services are not eligible for reimbursement. 
 
We looked at this coder's review, the file, and Medicare rules. 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 pay for physical therapy services provided to the enrollee on May 31, 2020 through June 4, 2020.