Persius/hicric huggingface dataset:
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 enrollee is still in an acute care 
setting, and has multiple medical conditions. The Plan denied your request. The Plan says transfer to a LTACH 
is not medically necessary at this time. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
lower level of care may be considered soon when the enrollee is more stable. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion, per diem (S9328) provided February 5, 2020 to April 22, 2020. 
 
You asked the Plan to pay for home infusion therapy, implanted pump. You say that the Plan denied the claim 
for non-par provider but you were referred by a par provider. This enrollee also has other dates of service that 
was allowed and paid by the plan. Please reprocess for payment. The Plan denied your request. The Plan says 
the Plan does not recognize this code for non-participating providers. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, S codes (temporary codes) 
are used to report drugs, services and supplies for which there are no national codes. Private insurers for claim 
processing, policies or programs primarily use these codes. These codes are not payable by Original Medicare. 
If original Medicare does not cover a service or a code, the Plan reserves the right to cover, but editing rules 
will be based on our guidelines, not original Medicare for that service or code. For S9328, the guidelines are 
that the Plan does not recognize this code for non-participating providers. Based on this information, we 
decided that Medicare rules for coverage of home infusion therapy, implanted pump have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy, implanted pump pain 
management infusion, per diem (S9328) provided February 5, 2020 to April 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit, high severity, provided on 
January 7, 2020. 
 
You asked the Plan to pay for the emergency department visit, problems of high severity (99285). You say that 
the Plan should pay this claim. The Plan denied your request. The Plan says a fractured ankle does not 
constitute a problem of high severity. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
 
We find that CPT code 99285 is not supported in the medical record. Specifically, a displaced fracture of ankle 
does not pose an immediate significant threat to life or physiologic function. Based on this information, we 
decided that Medicare rules for coverage of the emergency department visit, problems of high severity (99285) 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department 
visit, high severity, provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 the Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with spinal stenosis, low back pain, levoscoliosis, nerve pain legs, neck pain, and lumbar disc degeneration. 
The requested Vertiflex device is experimental. More research is needed to show safety and efficacy. The 
requested Vertiflex device is 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of hypertension, hyperlipidemia, coronary artery disease and stroke who presented to the acute 
hospital on 10/10/2020 with a fall and abdominal pain. He was treated in the hospital with intravenous and oral 
antibiotics for bacteremia (due to a PICC line and/or urinary source) and Clostridium difficile colitis. He has 
dysphagia and is fed via a percutaneous feeding tube. He has a Foley catheter due to urinary retention. He is 
weak and deconditioned and is working with physical and occupational therapy. He is not currently walking 
due to weakness and is maximum assist for transfers and moderate to maximum assist for activities of daily 
living. He is reported to be medically stable for discharge.  
 
Based on the medical records provided 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 does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on July 14, 2020, by an 
OON provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that there was a mistake in between your 
billing software changes and the date of service listed was overlooked. You also say that you have obtained 
authorizations for every other visit. The Plan denied your request. The Plan says the services were rendered by 
a non-participating provider. The Plan also says that prior authorization was not obtained. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on July 14, 
2020, by an OON provider.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The documentation does not reveal that the 
enrollee's functional level requires skilled therapy services with the specialized skill, knowledge and judgment 
 
 
of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a 
SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these 
services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services 
on an inpatient basis, in a skilled nursing facility 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 admission to a SNF 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 9, 2020 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of non-small cell lung cancer, chronic obstructive pulmonary disease, coronary artery disease 
and hypertension who presented to the acute hospital on 10/15/2020 with seizure activity. He was treated in the 
hospital with adjustment of his anticonvulsant medication and neurology consultation. He is weak and 
deconditioned and is working with physical and occupational therapy. He is walking 150 feet with a rolling 
walker with maximum assistance and is moderate assist for transfers and activities of daily living. He is 
reported to be medically stable for discharge. 
 
Based on the medical records provided 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 does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on April 
28, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not informed 
of the charges and disagree with them. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on April 28, 2020. The allowed amount is $4,565.70 and 20% of that is 
$913.14.  
 
You have been asked to pay the total coinsurance amount of $913.14 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of metatarsal fracture provided on February 
11, 2020. 
 
You asked the Plan to pay for closed treatment of metatarsal fracture; without manipulation, each (28470). You 
say that the enrollee was seen in the Emergency Room for this medically necessary procedure. The Plan denied 
your request. The Plan says the submitted records do not indicate that closed treatment of a metatarsal fracture 
was performed. 
 
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 28470 is not supported in the medical record. Specifically, the record does not show 
that any treatment of the foot was done. Based on this information, we decided that Medicare rules for 
coverage of closed treatment of metatarsal fracture; without manipulation, each (28470) have not been met. 
Therefore, we decided that the Plan does not have to pay for closed treatment of metatarsal fracture provided 
on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture with a flexible base (D5225) and 
the lower partial denture with a flexible base (D5226) provided on July 29, 2019. 
 
You asked the Plan to pay for the dental items. You say that you received a letter from the plan advising you 
should return to the fabricating provider for the remake of the indicated dentures at no cost. You say that the 
partial dentures you received do not have a flexible base. You say that you do not trust the provider office in 
this case. You also say that the dentures should have been replaced at no cost. The Plan denied your request. 
The Plan says partial dentures with a flexible base are subject to a $220 copayment. The Plan also says that you 
signed a treatment plan agreeing to the treatment and fees that you received. 
 
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 partial dentures with a flexible base 
are subject to a $220 copayment. The record shows that partial dentures were ordered. This type of
partial dentures are considered flexible. Therefore, we decided that the Plan does not have to pay for the upper 
partial denture with a flexible base (D5225) and the lower partial denture with a flexible base (D5226) provided 
on July 29, 2019.  
 
Your complaint about not trusting the provider office in this case is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97163) provided on July 29, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the 
appealed code does not appropriately reflect the services provided by the PTA. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the services of a physical 
therapy assistant shall not be billed as services incident to a physician/NPP's service. 
 
In this case, the CPT Code Manual definition of code 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family.  
 
We find that CPT code 97163 is not supported in the record. Specifically, the record indicates that these 
services were rendered by a physical therapy assistant. Services provided by a physical therapy assistant cannot 
be billed as services incident to a physician. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for physical therapy services (97163) provided on July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone/APAP tab 10-325 mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is an oral self-administered drug. 
 
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 Hydrocodone/APAP tab 10-
325 mg for the enrollee.