Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
28, 2020, to May 26, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the claim for dates of service January 28, 2020, to March 27, 2020 and 
March 28, 2020, to May 26, 2020 are a 59-day episode of care including from date.  
 
 
Per Medicare guidelines, plan of care is paid based on a 60-day episode of care (before January 1, 2020) or a 
30-day period of care (on or after January 1, 2020). The Plan states the date of service billed is after January 
01, 2020, a 30-day period of care is eligible, but provider has billed a 60-day period of care. Therefore, per the 
CMS guidelines we find that the Medicare rule for payment of this claim has not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted is not billed 
appropriately in regard to days billed and the requirements for this type of claim. The Plan states a corrected 
claim would be reviewed if submitted. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from 
January 28, 2020, to May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 30 and 31 and crowns 
(D2740) for teeth # 30 and 31. 
 
You asked the Plan to pre-approve the crown and core build up for tooth # 31. You say that the enrollee's teeth 
have large caries present. You also say that build up is needed due to minimal tooth structure. The Plan denied 
your request. The Plan says the requested services do not meet the criteria for coverage. 
 
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. The Plan covers the crown and 
core build up for tooth # 31 when the services are medically necessary and reasonable.  
 
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 crown and core build up for tooth # 
31. Our reviewer says that the core build up and crown for tooth # 31 are not medically necessary. Our 
physician reviewer found the provided x-rays and intra-oral photos reveal a significant missing section of tooth 
#31. The reviewer found that there is not enough structural damage to warrant a crown. Therefore, the 
reviewer found that the crown and core build up for tooth # 31 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown and core build up for tooth # 31 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 30 and 31 and crowns 
(D2740) for teeth # 30 and 31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says an 
out-of-network provider may be needed if the Plan does not have a doctor who can provide the services that are 
needed to treat your problem. The Plan says that this request can be safely given by an in-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 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 
physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the core build up. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says core build up is not listed as 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. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services you received from June 
16, 2020, to June 29, 2020. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford to pay a 
copayment for every dialysis treatment. The Plan denied your request. The Plan says you were charged this 
coinsurance correctly. 
 
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 20% 
coinsurance for dialysis services.  
 
Records show that you had seven dialysis visits from June 16, 2020, to June 29, 2020. You have been asked to 
pay 20% coinsurance for the dialysis services, for a total of $455. 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 
coinsurance for dialysis services you received from June 16, 2020, to June 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
enrollee can perform a home exercise program independently. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
The file shows that the Plan has agreed to pre-approve 6 physical therapy visits. 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 additional services. Our physician reviewer found that the 
enrollee has a past medical history of left wrist and hand stiffness and pain who has been receiving physical 
therapy services. She appears to have improvement in her pain and function with therapy, and is able to 
perform activities of daily living. Further therapy at this point does not appear to be likely to achieve any 
significant improvement in her symptoms or functional status. She can be maintained with a home exercise 
program. Therefore, additional services are not medically reasonable or necessary 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 additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 16, 
2020, through June 14, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the member has no skilled therapy or skilled nursing service needs. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided, there 
is no documentation that the patient required skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment for dates May 16, 2020, through June 14, 2020. 
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 pay for skilled nursing facility (SNF) care provided on May 16, 2020, through June 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on May 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the medical documentation submitted did 
not include a lab report or lab results for these tests. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record indicates that the Plan's decision was based on clinical 
information from the provider. The Plan failed to forward any clinical documentation. It is the burden of the 
Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find 
in your favor. Therefore, we decided that the Plan has to pay for laboratory services provided on May 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation inpatient mental health care provided from 
December 9, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. 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 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 pre-approve inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 9, 
2020, forward as this patient was not shown to be a danger to themselves or others. The patient was not 
showing any auditory or visual hallucinations and was cooperative/compliant with treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation inpatient mental health care provided from December 9, 2020, 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on June 20, 2019. 
 
You asked the Plan to pay for the services provided. You say that the records clearly state 3 nerves in the knee 
were injected. The Plan denied your request. The Plan says the documentation did not support the units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
The file shows that a genicular nerve block for the superior lateral, superior medial, and inferior medial nerves 
was provided. We find that 3 units of CPT code 64450 were billed for the services provided. We looked at the 
file and the rules. If a physician injects the superior medial and lateral branches and inferior medial branches of 
the left genicular nerve, only one unit of service of CPT code 64450 may be reported. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the injection services provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided June 9, 2020. 
 
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says documentation does not support the CPT code 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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intra service time, patient age 
5 years or older 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the record does not show 
that another trained observer was present when the procedure was performed. Based on this information, we 
decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for sedation services (99152) provided June 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for advanced life support (A0427) and specialty care (A0434) 
provided on December 14, 2019. 
 
You asked the Plan to pay for advanced life support and specialty care. You say that this should be paid 
because the ground ambulance did not provide medical care. The Plan denied your request. The Plan says these 
services cannot be paid. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. When 
a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance 
may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer 
to the air ambulance. Medicare does not regulate the compensation between the BLS entity and the ALS entity. 
 
The services at issue were provided during ground transportation to an air ambulance. The ground ambulance 
may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer 
to the air ambulance, and the services provided by the air ambulance provider are considered paramedic 
intercept services. Therefore, we decided that the Plan does not have to pay for advanced life support (A0427) 
and specialty care (A0434) provided on December 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 19, 2019, to 
October 12, 2019 at an ALF. 
 
You asked the Plan to pay for the skilled nursing services. You say that you have paid for these bills out of 
pocket, and it is causing you great financial hardship. The Plan denied your request. The Plan says the services 
were rendered by a non-participating provider, who is not certified with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that rules say that Medicare pays for services only 
when they are furnished by a provider or supplier enrolled in the Medicare program. The rules also say that 
assisted living facilities are not eligible to enroll in the Medicare program. 
 
We looked at 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 19, 2019, to October 12, 2019 at an ALF.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on April 1, 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 Plan says 
that the enrollee elected hospice on April 1, 2020. The Plan also says that this date of service is paid under the 
Medicare hospice benefit. 
 
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 the skilled nursing services provided on April 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional skilled nursing services. 
 
You asked the Plan to pre-approve 12 skilled nursing visits (G0299). You say that the enrollee needs wound 
care from a registered nurse. The Plan denied your request. The Plan says 12 additional skilled nursing visits 
are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 12 Direct skilled nursing services of a 
registered nurse (rn) in the home health or hospice setting, each 15 minutes (G0299). Our reviewer says that the 
services are not medically necessary. Our physician reviewer found skilled nursing services are not required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The 
 
 
documentation reveals stable size of the wound without infection and nursing notes state wound is decreasing 
since 10/5/20 without a change in measurements. The wound care is not complex. The caregiver has been 
trained in wound care. The request for additional skilled nursing beyond what was approved by the plan is not 
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 12 Direct skilled nursing services of a registered nurse (rn) in the home health 
or hospice setting, each 15 minutes (G0299) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 additional skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you are having trouble getting to your 
toilet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 22, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you should only be responsible for the 
$325 copay for the hospital stay. The Plan denied your request. The Plan says self-administered drugs are not 
covered services under your plan. 
 
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 pay for the self-administered drugs 
provided on May 22, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.