Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from December 20, 2021, 
through December 23, 2021. 
 
You asked the Plan to pay for the medical services. You say that the services should be paid as they were 
medically necessary. The Plan denied your request. The Plan says Medicare records indicate that the enrollee 
passed away on December 19, 2021. As such, payment cannot be made for services provided after that date. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the medical services have been met. 
Specifically, the Medicare database shows a date of death for this enrollee of December 19, 2021. Until the 
Medicare system is updated with a corrected date of death, if applicable, payment cannot be made for these 
services. Therefore, we decided that the Plan does not have to pay for the medical services provided from 
December 20, 2021, through December 23, 2021.
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 you do not have anyone at home to help with 
walking and if you cannot walk on your own, you should not be at home by yourself. You say rehab is the 
natural progression to help your hip heal. The Plan denied your request. The Plan says you are medically stable 
and do not require an inpatient setting for 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 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 you do not require intensive rehabilitation to recover from hip replacement 
surgery. Uncomplicated hip replacement rehabilitation is performed at home or in skilled facilities. The 
physical therapist recommended discharge to a skilled facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services billed with codes A0425-RH and A0427-RH 
provided on June 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this bill needs to get paid. The Plan denied 
your request. The Plan says that services with a status indicator of X are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services billed under the Physician Fee 
Schedule that have a status indicator of X are statutorily excluded because the services do not meet the 
definition of 'physician services' for fee schedule payment purposes. 
 
We agree with the Plan's assertion that the ambulance codes in dispute have a status indicator of X on the 
Physician Fee Schedule and would therefore not be payable under that fee schedule.  However, these are 
ambulance services, which are paid under the Ambulance fee schedule.  The Plan has provided no argument or 
substantiating evidence as to why this ambulance claim has not been paid under the ambulance fee schedule.  
The burden is on the Plan to thoroughly explain and support its denial.  By failing to address why these services 
should not be covered under the Ambulance fee schedule, we find that the Plan has not met this burden. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for 
ambulance services billed with codes A0425-RH and A0427-RH provided on June 5, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient care (99232) provided on August 29, 
2022. 
 You asked the Plan to pay for the service. You say that the initial consult is not bundled into the surgery on 
date of service, August 30, 2022. The Plan states the initial consult is reimbursable due to services rendered 
prior to the date of surgery. The Plan denied your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Procedure code 99232 that was 
provided on August 29, 2022, was bundled as part of the global surgical fee because it was reported the day 
prior to the major surgical procedure, 61304 (Craniectomy or craniotomy, exploratory; supratentorial).  A 
modifier was not billed on the claim to represent the services as separate/distinct. Therefore, we decided that 
the Plan does not have to pay for initial hospital inpatient care (99232) provided on August 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from July 15, 
2022, to August 13, 2022. 
 
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 this was not reported correctly. 
 
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 procedure codes Q5001 and G0151 are not supported in the medical record. Specifically, these 
codes were not billed with the same revenue code. 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 
home health services provided to the enrollee from July 15, 2022, to August 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic continuous glucose 
monitoring (CGM) device (K0553) provided March 12, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that please find attached records in order to 
process the claim. The Plan denied your request. The Plan says the Plan does not have the information needed 
to consider this charge. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain valid relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the Plan requested that all treatment records be provided which all treatment 
records should include the anesthesia report and time, history and physical report, documentation to support 
physical status modifier billed, evaluation report and the operative report. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for supply allowance used with a therapeutic continuous glucose monitoring (CGM) 
device (K0553) provided March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON office visit. You say that these services were needed prior to her 
surgery and were performed at a network provider's office/facility. The Plan denied your request. The Plan says 
the documentation does not show that a network provider was involved in this case, and that no authorization 
was obtained for this visit. 
 
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 visit provided on September 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has 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 the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not  
 require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) supply 
allowance (A4595) provided October 4, 2022. 
 
You asked the Plan to pay for a TENS supply allowance. You say that please review the claim denial for 
accuracy. E0730 is an accepted procedure code according to the Plan's Durable Medical Equipment Reference 
List NCD 280.1 The Plan denied your request. The Plan says evidence of misrepresented service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, per the records the proof of delivery status reflects 
return to sender. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for a transcutaneous electrical nerve 
stimulation (TENS) supply allowance (A4595) provided October 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (Q5001 and G0151) provided from 
June 9, 2022, through June 24, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Codes Q5001 and 
G0151 is not billed with the same REV code i.e for Q code the Rev code is 0420 and for G code is 0421. 
Therefore, we decided that the Plan does not have to pay for the home health services (Q5001 and G0151) 
provided from June 9, 2022, through June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 18, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the criteria 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 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF at this time. The enrollee is currently being medically managed in the acute care hospital and received a transfusion 
on February 6, 2023. He continues to have tachycardia and low blood pressure with dizziness in therapy on 
February 7, 2023. The enrollee currently does not require intensive physician and nursing oversight in an IRF 
and still needs medical management in the acute care hospital.  While the enrollee may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that the 
patient requires or can tolerate this therapy on an intensive IRF level 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99205 billed for date of service July 11, 2022. 
 
You asked the Plan to pay for code 99205. You say that this service was medically necessary for the patient. 
The Plan denied your request. The Plan says this service was 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. 
 
In this case, the CPT Code Manual definition of code 99205 is Office or other outpatient visit for the evaluation 
and management of a new patient which requires a medically appropriate history and/or examination and high 
medical decision making. Records show that this patient was seen by another provider with the same specialty 
and same taxonomy on May 17, 2022, so this service should not have been billed as a new patient visit. 
Medicare rules define a new patient as a patient who has not receive any professional services from the physician or physician group practice (same physician specialty) within the previous three years.  Because the 
visit with the other provider within the group was within this 3-year window, a new patient visit is not 
appropriate. 
 
Based on this information, we decided that Medicare rules for coverage of code 99205 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99205 billed for date of service July 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided on June 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the TENS supply allowance. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended lifetime use of the equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 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 transcutaneous electrical nerve stimulation 
(TENS) supply allowance (A4595) provided on June 13, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that in this 
case, the documentation doesnt support that you require additional skilled rehab services to provide treatment 
that is medically necessary. You do not require additional skilled rehab services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four home health physical therapy visits.
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 the enrollee does not 
meet all the required criteria for admission to an Inpatient Rehabilitation Facility, medically necessary care 
may be provided safely in a different level of 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 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 there is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.