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

 
We decided that the Plan does not have to pre-approved the continuation of home health visits for 2 hours a day 
7 days a week. 
 
You asked the Plan to pre-approved the continuation of home health visits for 2 hours a day 7 days a week. 
You say that the enrollee has a routine and needs to continue receiving the same amount of care. The Plan 
denied your request. The Plan says the enrollee's needs can be met with fewer hours of care. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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-approved the continuation of home health visits 
for 2 hours a day 7 days a week. Our reviewer says that the requested services are not medically necessary. Our 
physician reviewer found the documentation does not support that the additional requested services are services 
necessary and reasonable to meet the patient's needs and to improve and maintain the patient's overall health 
status. The documentation indicates that the patient's daily living needs can be met safely and effectively in the 
allotted time and the additional time 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 the continuation of home health visits for 2 hours a day 7 days a week have not 
been met. Therefore, we decided that the Plan does not have to pre-approved the continuation of home health 
visits for 2 hours a day 7 days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder arthroscopy services (CPT 29823). 
 
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 the operative report did not include sufficient documentation to meet the guidelines of a surgical 
shoulder arthroscopy with extensive debridement; therefore, this code cannot be verified. 
 
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 29823 is "Arthroscopy, shoulder, surgical; debridement, 
extensive." 
 
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 
operative report does not include sufficient documentation to support extreme debridement was performed. 
 
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 shoulder arthroscopy services (CPT 29823).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care beginning October 9, 2020. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do 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 beyond the last covered date. You 
do not have complex wound care or other ongoing SNF level SN need. Your functional level does not require 
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 beyond the last covered date. 
You do 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, you do not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care beginning October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (CPT 77002). 
 
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 the procedure requires modifier 26. 
 
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 77002 is "Fluoroscopic guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure)." 
 
We find that CPT code 77002 is not supported in the medical record. Specifically, the professional 
interpretation of a diagnostic test must be separately billed with modifier-26. This claim was not billed 
correctly. 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 fluoroscopic guidance for needle placement 
(CPT 77002) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe panoramic x-ray (D0330) provided on July 6, 2020.You asked the Plan to pay forthe dental service. You say that your dentist ordered this service. You also say that they should have known it was not covered.ThePlan denied your request. The Plan says that panoramic x-rays are covered every 36 months. The Plan also says that the frequency limit for this service has been exceeded.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. The Plan claimed that the frequency limit for panoramic x-rays has been exceeded. The Plan did not provide any documentation to substantiate this claim. Without documentation to show that the enrollee had received this or an intraoral complete series of x-rays within the last 36 months, this claim cannot be substantiated.Therefore, we decided that the Plan has to pay forthe panoramic x-ray (D0330) provided on July 6, 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 semi-electric hospital bed (CPT Code E0260). 
 
You asked the Plan to pre-approve the DME. You say that the member has stage 4 ovarian cancer and 
shortness of breath. You state the hospital bed would improve their quality of life. The Plan denied your 
request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the documentation does not clearly reveal that patient's condition has failed positioning of the bed in 
ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The 
documentation does not support a need for an immediate change in body position or frequent changes in body 
position or special attachments that cannot be fixed on an ordinary bed. The medical progress reports to not 
indicate shortness of breath or a clear rationale for this bed. The request for a semi-electric hospital bed is not 
medically necessary for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve semi-electric hospital bed (CPT Code E0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld.  The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care 
needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care. 
 
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 it was not expected you would improve in a 
reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and 
denied any auditory or visual hallucinations. You were 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 you did not have 
dangerousness to self or others but was compliant with your treatment. The health plan?s denial of continued 
inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment 
beyond the date in question as you were 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 
patient?s condition or for the purpose of diagnosis beyond the date in question. Our physician was unable to 
find an individualized treatment plan however the entire chart is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review the records provided for the admission does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question as you were not shown to be a danger to yourself or others. You were not showing any 
auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats 
the safety. 
 
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 of inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a standard-weight frame motorized/power 
wheelchair and DME supplies provided. 
 
You asked the Plan to reimburse you for the standard-weight frame motorized/power wheelchair and DME 
supplies. The Plan denied your request. The Plan says the items were provided by a non-Medicare certified 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that you purchased the standard-weight frame 
motorized/power wheelchair and DME supplies from an online company that is not a provider or a supplier that 
is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for a 
standard-weight frame motorized/power wheelchair and DME supplies provided.
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. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not meet the CMS coverage criteria for an IRF admission based 
on lack of medical and nursing needs and current functional status. The enrollee is generally medically stable 
and there is no evidence of complex medical issues. There is no evidence of medical issues that require 
monitoring by an inpatient rehab physician three times per week. The documentation does not support that 
there is a need for an intensive therapy program and an interdisciplinary approach to rehab care. He is already 
receiving therapy in SNF and making appropriate progress. His rehab needs can be met in an alternate, less 
intense 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crowns provided on March 25, 2020.You asked the Plan to pay forthe crowns. You say that you were informed there was no maximum, no deductible, cleanings and exams were covered two times per year, bitewings are covered one time per year and there was 100% coverage on all covered codes. You say that if you were informed of the maximum this would have been avoided.The Plan denied your request. The Plan says the maximum benefit allowed by your dental plan for this benefit year has been paid.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, you also have a maximum annual allowance of $250 for non-Medicare-covered preventive and comprehensive dental services. The Plan paid $250 toward dental services provided on January 9, 2020, and February 4, 2020, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay forthe crowns provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan?s denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollees 
care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment delivery services (CPT 77412) provided 
to the enrollee on April 8, 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 payment is not allowed for this service, because it was billed with a modifier that is 
inappropriate for this procedure code. 
 
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 77412 is "radiation treatment delivery, more than 1 
MeV." 
 
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 modifier 
TC would not be appropriate in this case.  Modifiers are used to indicate that a service or procedure has been 
altered by some specific circumstance, or to provide more specific information regarding the procedure 
performed.  Most modifiers apply to a specific group of codes and may only be reported with those specified 
codes. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiation treatment delivery services (CPT 77412) provided to the enrollee on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fororthoses provided to the enrollee on April 10, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.The 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 the denied codes is:HCPCS L1851:Knee orthosis (ko), single upright, thigh and calf, withadjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelfHCPCS L2397:Addition to lower extremity orthosis, suspension sleeveHCPCS L2385:Addition to lower extremity, straight knee joint, heavy duty, each jointWe 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation did not include a valid proof of delivery ticket. The documentation does not include a itemizedshipping/billing invoice, and date included on commercial invoice does not support date of service billed.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay fororthoses provided to the enrollee on April 10, 2020.