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

 
We decided that the Plan does not have to pay for the home health care services provided from March 17, 
2021, to March 31, 2021. 
 
You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says the 
non-contracted provider submitted the RAP claim on August 13, 2021 for the home health care period which 
started on March 17, 2021, and ended on March 31, 2021. The Plan also says that the non-contracted provider 
submitted the final claim on September 13, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from March 17, 2021, to March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 13, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for inpatient 
psychiatric care are no longer 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 the continuation of inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically necessary. Our physician 
reviewer found that you are an 85-year-old female who was admitted to the acute inpatient psychiatric 
hospitalization on May 13, 2022, with anxiety disorder, unspecified. Based upon review the records provided it 
was not expected that you would improve in a reasonable period of time as you did not have dangerousness to 
self or others, auditory or visual hallucinations or behaviors threatening acute safety. You were cooperative and 
compliant with treatment. 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 as you did not have dangerousness 
to self or others. 
 
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 inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric care from May 13, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4260), and an incisional biopsy 
(D7285) provided by an out-of-network provider on September 21, 2021. 
 
You asked the Plan to pay for an osseous surgery and an incisional biopsy. You say that you would like this to 
be covered. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
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.  
 
  
Therefore, we decided that the Plan does not have to pay for an osseous surgery (D4260), and an incisional 
biopsy (D7285) provided by an out-of-network provider on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the preventive procedure (D1999) provided on January 18, 2022. 
 
You asked the Plan to pay for the preventive procedure. You say that you do not agree with the denial because 
the provider is a contracted provider. You also say that you have not received the services that you paid for out 
of pocket. The Plan denied your request. The Plan says that this service is not a covered benefit. 
 
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 did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the preventive procedure (D1999) provided on January 18, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a palliative treatment 
of dental pain (D9110) provided by a participating provider on November 16, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and a palliative treatment of dental pain. You say that 
these services were medically necessary. The Plan denied your request. The Plan says the services that were 
provided were not covered dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a palliative treatment of dental pain (D9110) provided by a participating provider 
on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on December 20, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 outpatient hospital services provided on December 
20, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-level lumbar fusion procedure. 
 
You asked the Plan to pre-approve a multi-level lumbar fusion. You say that the requested procedure is a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the 
requested procedure have not been met. 
 
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 a multi-level lumbar fusion. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that detailed documentation is not evident regarding instability in the lumbar 
spine at all of the requested fusion levels. The L5-S1 disc level did not show stenosis suggestive of potential 
impending/inevitable temporary intra-operative instability. Additionally, there is a documented body mass 
index of 48.6 kg/m2, a plausible risk factor for fusion healing and/or post-operative complications. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a multi-level lumbar fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a multi-level lumbar fusion procedure.  
 
Your complaint about being treated without empathy by a customer-service representative of the Plan 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 21, 2021, to 
February 9, 2021, as billed with Diagnosis Related Group (DRG) 178. 
 
You asked the Plan to pay for inpatient care billed with DRG 178. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 178 is not supported as the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in the 
medical record. The Plan argues that DRG 194 is more appropriate in this case, with diagnosis pneumonia, 
unspecified organism (J18.9) instead. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 inpatient care billed with DRG 178. Our 
reviewer says that the diagnosis of pneumonia due to other gram-negative bacteria (J15.6) is not supported in 
the medical record. Our physician reviewer found that the enrollee presented to the emergency department 
(ED) on January 31, 2021, with complaints of shortness of breath, a nonproductive cough, and slight chest 
pain. The enrollee was oxygen dependent, had chronic obstructive pulmonary disease (COPD) and lung cancer, 
and was undergoing chemotherapy. A computed tomography scan of the chest was obtained which noted a left 
apical mass consistent with neoplasm, multiple other ground glass, nodular areas, and a nodular opacity in the 
right upper lobe. Documentation indicated that presenting symptoms were most likely due to progression of his 
cancer and possible superimposed pneumonia with suspected gram-negative anaerobes. The enrollee was also 
diagnosed and treated for a COPD exacerbation. Initial antibiotics included Zosyn and Vancomycin. These 
antibiotics were discontinued after two days, and the enrollee was transitioned to Azithromycin. While the 
enrollee may have been at risk for gram-negative pneumonia, the clinical evidence did not support the 
condition. The review has determined that the medical records did not support the billing of pneumonia due to 
other gram-negative bacteria (J15.6). 
 
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 care billed with DRG 178 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 21, 2021, to February 9, 
2021, as billed with Diagnosis Related Group (DRG) 178.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an excision of nail and nail matrix (11750) to be provided in an 
outpatient hospital setting. 
 
You asked the Plan to pre-approve an excision of nail and nail matrix in an outpatient hospital setting. You say 
that the requested outpatient setting is a medical necessity for the enrollee. The Plan denied your request. The 
Plan says that medical necessity rules for coverage for the requested outpatient setting have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an excision of nail and nail matrix in an 
outpatient hospital setting. Our reviewer says that the rendering of the requested services in an outpatient 
hospital setting is considered medically reasonable and necessary in this case. Our physician reviewer found 
that the requested Winograd matrixectomy is a surgical procedure that requires surgical excision of skin and 
toenail matrix surrounding the nail bed. At times this procedure may require hemostasis to be performed 
adequately. Suturing of the excised tissue area is also involved. It is reasonable for you to receive monitored 
anesthesia care for this procedure. A high level of sterilization is also required due to the proximity of the 
matrix to the distal phalanx. An outpatient surgical facility with monitored anesthesia care and sterility is 
medically reasonable and 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 an excision of nail and nail matrix in an outpatient hospital setting have been 
met. Therefore, we decided that the Plan has to pre-approve an excision of nail and nail matrix (11750) to be 
provided in an outpatient hospital setting.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nasal/sinus endoscopy, surgical; with concha bullosa 
resection (CPT code 31240-50), nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of 
tissue from maxillary sinus (CPT code 31267-50-51), nasal/sinus endoscopy, surgical with ethmoidectomy; 
total (anterior and posterior) (CPT code 31255-50) and submucous resection inferior turbinate, partial or 
complete, any method (CPT code 30140-50) provided on March 10, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the submitted medical records do not support that the services were performed on the 
left side; therefore, the validity and accuracy of the billed code and modifier 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. 
 We asked our coder 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 found the modifier 50 is to be 
used to report bilateral procedures performed during the same operative session by the same physician. The 
submitted medical records do not support that the services were performed on the left side. Consequently, the 
accuracy of the billed code with the modifier 50 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 nasal/sinus endoscopy, surgical; with concha bullosa resection (CPT code 31240-50), 
nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus (CPT 
code 31267-50-51), nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) (CPT 
code 31255-50) and submucous resection inferior turbinate, partial or complete, any method (CPT code 30140-
50) provided on March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you received oral medications and 
had stable vital signs. You were at a maximal assist of 2 to dependent level for functional mobility. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says medical necessity rules for 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 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 that you are medically stable and have no medical complexity and do not need 
physical medicine & rehabilitation physician close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. The complexity of 
your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on November 10, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the office services. You say that it was medically necessary to treat the enrollee 
and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider, and the authorization was denied at the time of service. 
  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 the office services provided on November 10, 
2021, by an OON provider.