Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 6, 2021, through
April 10, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically
necessary. The Plan denied your request. The Plan says that services could have been provided in an alternate
level of care such as observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found based on the documentation describing multiple outpatient attempts to treat the diverticulitis
with failure and the fact that an aortic dissection was noted on imaging and was at the time not clear if acute or
not, the intensive care unit (ICU) admission was appropriate and would have been expected to cross 2
midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from April 6, 2021, through April 10, 2021.
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 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 on IRF criteria. The Plan states that they
suggest care at a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient therapy visits (97110, 97140,
97530, 97161) provided from June 3, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for the therapy sessions. You say that you feel you would have to
pay less for these services with Original Medicare. The Plan denied your request. The Plan says these claims
were processed correctly, and your cost-sharing was assessed in accordance with your contract.
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 a $40
copayment for physical therapy services.
You have been asked to pay a $40 copayment for each of the physical therapy sessions. 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 copayment for the outpatient therapy visits (97110, 97140, 97530, 97161) provided
from June 3, 2021, to June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on August 5,
2021.
You asked the Plan to pay for the dental service. You say that you told the dental office that you only wanted a
cleaning that was going to be covered by your insurance. You also say that it was not until after the services
were rendered that you were advised that the full mouth debridement was not a covered benefit The Plan
denied your request. The Plan says the full mouth debridement is not 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 full mouth debridement is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full
mouth debridement (D4355) provided on August 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) home health physical therapy visits and five
(5) home health occupational therapy visits.
You asked the Plan to pre-approve the services. You say that you cannot walk out of the home to go to physical
therapy, so they come to your home. The Plan denied your request. The Plan says there is no clinical evidence
to support the medical necessity of the services.
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 services. Our physician reviewer
found the requested physical and occupational therapy is not generally accepted as specific and effective
therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the
records do not demonstrate that the unique skills of a professional therapist are required to safely and
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or
by or under the supervision of a therapist. You and your caregiver have been instructed in a seated home
exercise program. Sundowning, dementia, and anxiety are limiting your full participation in therapy. On
December 10, 2021, you and your caregiver demonstrate safe transfers with appropriate body mechanics and
equipment. The requested services are not part of a maintenance program, are the specialized skill, knowledge
and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your
current condition or to prevent or slow further 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve eight (8) home health physical therapy visits and five (5) home health occupational therapy
visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided July 20, 2021.
You asked the Plan to pay for the limited oral exam. You say that you were not aware there were frequency
limits for exams. The Plan denied your request. The Plan says you have exceeded the frequency limit for this
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. The Plan covers the limited
oral exam twice per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that an oral exam was
previously covered on January 6, 2021, and May 26, 2021. Based on this information, we decided that the
Plan's frequency limit for coverage of the limited oral exam has been exceeded.
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused
(D0140) provided July 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 29, 2021, through November 29, 2021.
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 was 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 in the Medicare rules section 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 there is no documentation that the patient required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from October 29, 2021, through November 29, 2021. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from October 29, 2021, through November 29, 2021. Daily skilled services were not required from October 29, 2021, through November 29, 2021. The enrollee did not require the services on an inpatient basis, only in a SNF setting. Services in the nursing facility appear custodial in this case from October 29, 2021, through November 29, 2021. 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 from October 29, 2021, through November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment - includes modification and
placement (D6056) and abutment supported porcelain fused to metal crown (noble metal) (D6061) provided
June 10, 2021.
You asked the Plan to pay for the prefabricated abutment and abutment supported porcelain crown. You say
that you believed the services would be covered. The Plan denied your request. The Plan says these services are
not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the prefabricated abutment - includes
modification and placement (D6056) and abutment supported porcelain fused to metal crown (noble metal)
(D6061) provided June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extended ophthalmoscopy (92201) ophthalmic ultrasound, LT, RT (76512) scanning computerized ophthalmic diagnostic imaging (92134) provided August 11, 2020.
You asked the Plan to pay for the diagnostic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.
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, we find that CPT code 92201, 76512 and 92134 is not supported in the provided medical record received. Specifically, the records provided did not include any documentation of either ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral (99201), ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan (76512) or of scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134). The records show that the Plan made several attempts to obtain the additional records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for extended ophthalmoscopy (92201) ophthalmic ultrasound, LT, RT (76512) scanning computerized ophthalmic diagnostic imaging (92134) provided August 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on December 18, 2020.
You asked the Plan to pay for the laboratory testing. You say that the service should be covered. The Plan denied your request.
The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on December 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 25, 2021 and billed under codes 95886, 95910, 95937 and 95957.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary provide the medical records to support the services billed. In this case, the records provided are insufficient to support these services s billed. Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 25, 2021 and billed under codes 95886, 95910, 95937 and 95957.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a transcatheter placement of an intravascular stent (37239)
provided on April 28, 2021, by an out-of-network provider.
You asked the Plan to pay for a transcatheter placement of an intravascular stent. You say that the services at
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-
network care have not been met.
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 had network providers
available who could have provided 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 a transcatheter placement of an intravascular stent
(37239) provided on April 28, 2021, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eleven (11) home health physical therapist visits (CPT code G0151), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee can walk seventy-five (75) feet with a rolling walker, they
require little to no help with moving in bed, standing up, and getting to the toilet. The Plan states the records also show that the enrollee has caregivers available who can help the enrollee with many of their daily living tasks.
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 services. Our physician reviewer found there is no documentation that skilled therapy services beyond what have been approved by the health plan are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee is contact guard to minimum assist for transfers and is walking seventy-five (75) feet with contact guard assistance with a rolling walker. Records do not document why the eight (8) approved physical therapy visits along with the home exercise program are inadequate to treat the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve eleven (11) home health physical therapist visits (CPT code G0151), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
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 psychiatric treatment. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review
of the records provided, you do not meet criteria for acute inpatient mental health treatment as you were not
shown to be a danger to yourself or others, no auditory or visual hallucinations. You were noted to be
cooperative and compliant with treatment while not showing any aggressive behaviors.
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 psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and
periodontal maintenance (D4910) provided on May 20, 2021, by a Medicare opt out provider.
You asked the Plan to pay for the dental services. You say that while you have opted out of Medicare, you have
not opted out with the enrollee's plan. The Plan denied your request. The Plan says payment cannot be made for
dental service performed by a provider that has opted out of Medicare.
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, dental services performed by a
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided
that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and periodontal
maintenance (D4910) provided on May 20, 2021, by a Medicare opt out provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on July 13, 2021.
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 procedure code 74018 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 74018 (abdomen x-ray, one view) and 74022 (abdomen x-ray, complete series). Code 74018 is a column II code with a modifier indicator of 1 when billed with column I code 74022. Code 74018 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdomen x-ray rendered on July 13, 2021.