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

 
We decided that the Plan does not have to pre-approve six additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve the additional visits. You say that the enrollee needs taxing efforts to 
ambulate. The Plan denied your request. The Plan says the services can be completed within the five approved 
visits. 
 
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 the additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found in 
this case, the documentation doesnt support that you require skilled nursing services beyond the 5 visits that 
have been approved by the health plan. You do require intermittent nursing visits for care of an indwelling 
urinary catheter and monitoring but this can be reasonably accomplished within the authorized skilled nursing 
 
 
visits. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The additional visits are 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the orthosis (L1833). You say that the claim should be paid. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan. We have also determined that 
these services are not urgent or emergent, nor were they 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 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 May 28, 2020 by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like reconsideration because you will do well in a rehab and not a skilled nursing facility.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.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 there are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, thefile, 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says your 
medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that you were admitted to the acute care hospital with multifactorial acute encephalopathy, 
alcohol withdrawal, acute on chronic respiratory failure, chronic obstructive pulmonary disease exacerbation, 
and pneumonia. You required intubation. Your prognosis is guarded, with hypotension requiring vasopressors, 
and intermittent fever. LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. 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. The clinical assessment does not support that you are reasonably expected to benefit from, and 
improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99152) provided on May 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
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 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 intraservice time, patient age 
5 years or older". 
 
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 use 
of CPT 99152 is not supported by the records provided. Our coding reviewer found that the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status was not documented in the operative report, and therefore cannot be verified. 
 
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 the services (CPT 99152) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palingen/Promatrx injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental and/or investigational. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PaliGen for the treatment of hip osteoarthritis has not been proven to be effective. There is a 
lack of evidence to support the use of PaliGen in patients with hip osteoarthritis. This service is therefore 
considered experimental or investigational. For this reason, the Medicare criteria of this service being 
medically reasonable and necessary is not met. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palingen/Promatrx injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full amount for guided tissue regeneration (D4266 x 
2), bone replacement graft for ridge preservation (D7953), and a cone beam CT (D0366). 
 
You asked the Plan to pre-approve the full amount for the dental services. You say that you are on disability. 
You say that you cannot afford to pay for the dental services that you need to have done. You say that implants 
are the most appropriate way to improve your dental situation. You also say that you believe the services 
should be covered in full. The Plan denied your request. The Plan says guided tissue regeneration is not listed 
as a covered service. The Plan says bone replacement graft for ridge preservation is not listed as a covered 
service. The Plan says cone beam CT is not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the full amount for 
guided tissue regeneration (D4266 x 2), bone replacement graft for ridge preservation (D7953), and a cone 
beam CT (D0366).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost for the urgent care visit. We decided that the Plan does not have 
to waive the cost for the urgent care visit.  
 
You asked the Plan to reduce the cost for the urgent care visit. You say that you weren't told the provider was a 
specialist. You say that you shouldn't have to pay $50 for each visit. The Plan says that the $50 copayment 
applied correctly. 
 
We decided that the Plan has to reduce the copayment for the urgent care visit.  
 
The records show that the services were provided at an urgent care facility. Your contract with the plan clearly 
says that you pay 20% coinsurance for urgently needed services at an urgent care center. The allowed amount 
is $50.51 (20% x $50.51 = $10.10). Therefore, we decided that the Plan has to reduce the cost for the urgent 
care visit.  
 
  
 
 
We also decided that the Plan does not have to waive the cost for the urgent care visit. 
 
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 urgently needed services at an urgent care center. Therefore, we decided that the Plan does not 
have to waive the cost for the urgent care visit. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the most recent records show that the 
enrollee has been medically stable. He is alert and appropriately oriented with no indication that he has a 
feeding tube, parental medications or complex wound care issues. The enrollee does not require skilled nursing 
or rehab services to effectively provide treatment, care, and/or services in order to improve his condition or 
perform a maintenance program to maintain his condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that you feel this procedure should be 
covered. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve a 
bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on March 23, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says they are not permitted to reimburse this code as a new item. 
 
The Plan must follow Medicare rules. The rules state that providers may bill CR durable medical equipment 
with the correct modifier. 
 
The code E0745 was billed with the NU modifier. The RR modifier is to be used when DME is to be rented. 
Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on March 
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on June 22, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 99214 is not supported in the medical record. Specifically, this code was billed with 
modifier GT. Modifier GT cannot be billed with this code. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit coded 99214 provided on June 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left shoulder. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic shoulder problems 
and has been evaluated. He is felt to have an impingement. He has been treated with NSAIDs and other 
conservative measures. The MRI is reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the left shoulder.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous electrical nerve stimulation (tens) 
device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee suffers from poorly managed 
migraine headaches. The Plan denied your request. The Plan says the device is not covered for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
The documentation in the case file shows that the requested device is being requested to treat chronic migraine 
headaches. We looked at the file, and Medicare rules. The rules say that headaches are a condition that are 
considered not medically reasonable and necessary for the requested device. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Transcutaneous electrical nerve stimulation (tens) device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of maxillofacial area for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is insufficient clinical information to approve the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found although the enrollee is 
asymptomatic, the fact there was an equivocal MRI scan 3/25/20 makes a 6 month surveillance CT scan 
reasonable. Such a scan would also comply with the surveillance plan of the oncologist and should be 
approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of maxillofacial area for the enrollee.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary as you are not medically stable and should remain in acute inpatient care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
cervical spine surgery. Your medical problems are not yet stable and additional acute inpatient medical 
management is required. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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 IRF admission and services.