Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0426) and 
ground mileage (A0425) provided on January 9, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the ambulance left the facility at 12:04, and the enrollee was discharged from the facility at 12:03. You also say 
that the enrollee was not an inpatient when they were transported, and this was denied incorrectly. The Plan 
denied your request. The Plan says this claim denied correctly because there is an inpatient claim on file for 
this date of service. The Plan also says that this was a facility to facility transfer while the enrollee was an 
inpatient, and the enrollee was never discharged per the claims history. 
 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 non-emergency ambulance 
transportation (A0426) and ground mileage (A0425) provided on January 9, 2022. have been met. The Plan 
denied this case stating the enrollee was under an inpatient admission during the time of transportation. No 
medical records have been submitted to show that the enrollee had been discharged prior to being transported. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0426) and ground mileage (A0425) provided on January 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on August 19, 2021. 
 
You asked the Plan to pay for the home health care services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) 
claim was not received within 5 calendar days from the start of care. 
 
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 on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) and the dental cleaning 
(D1110) provided by an out-of-network provider on February 7, 2022. 
 
You asked the Plan to pay for periodic oral exam (D0120) and the dental cleaning (D1110). You say that you 
were led to believe that you had out-of-network dental coverage. You say these same out-of-network services 
were covered six months ago. The Plan denied your request. The Plan says the services are not covered if they 
were performed out-of-network. 
 
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 periodic oral exam (D0120) and the 
dental cleaning (D1110) are not among those covered under this benefit when received by an out-of-network 
provider. The record shows the provider was out-of-network. Therefore, we decided that the Plan does not have 
to pay for the periodic oral exam (D0120) and the dental cleaning (D1110) provided by an out-of-network 
provider on February 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided from March 20, 2022, to March 21, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this has been covered in the past. You say 
that you did not want to add to your cost by going to the hospital for a meal. You also say that your wife would 
not have let you stay home if you were in distress still. The Plan denied your request. The Plan says since there 
was no transport provided on the dates of service in this case, there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 20, 2022 to March 21, 2022. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment, no transport, (A0998) provided from March 20, 2022, to March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found there is no documentation indicating that the member experienced at least a 50% improvement 
in pain relief and/or improvement in function measured from baseline using the SAME scale for at least three 
(3) months. The review has determined that the enrollee does not meet the LCD criteria for the requested 
epidural steroid injection. 
 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care and can be treated at a 
lower level of care such as at home with home health services or in residential care with a close follow-up with  
the enrollee's doctor. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) month rental of a non-invasive home 
ventilator. 
 
You asked the Plan to pre-approve three (3) month rental of a non-invasive home ventilator. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 three (3) month rental of a non-invasive 
home ventilator. Our reviewer says that the documentation does not support that the requested home ventilator 
is medically reasonable or necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and was recently hospitalized with acute on chronic hypercarbic respiratory failure. Bilevel positive airway pressure (Bipap) was highly effective in reducing the Carbon dioxide (CO2);  the 
partial pressure of carbon dioxide (PaCO2) decreased from 103 to 61.5 with only one day on bipap. Bipap has 
not been tried at home, with or without average volume-assured pressure support (AVAPS). Medicare does not 
pay for a ventilator when used as bipap. Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three (3) month rental of a non-invasive home ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve three (3) month rental of a non-invasive home 
ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three additional simple extractions (D7140 x3) and 
complete maxillary denture (D5110) provided on December 13, 2021, and December 28, 2021. 
 
You asked the Plan to pay for the additional extractions and denture. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says you have reached your annual dental maximum. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit while reprocessing the claim 
for the December 13, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the three additional simple extractions (D7140 x3) and 
complete maxillary denture (D5110) provided on December 13, 2021, and December 28, 2021.
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. You say that the enrollee's needs are not able to be 
met at the short-term acute hospital. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is a fall risk. The Plan denied your 
request. The Plan says the enrollee does not need skilled nursing or therapy. 
 
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 services. Our physician reviewer 
found that the enrollee is walking with a rolling walker with minimal assistance, is minimal assist for transfers, 
and is minimal assist for activities of daily living. She is reported to be medically stable for discharge on 
outpatient medications. The records do not document the need for intravenous medications, new tube feeding, 
or ostomy care or daily complex wound care. Although the enrollee requires skilled therapy services, the 
provided records do not document a significant decline in her functional status to necessitate daily inpatient 
skilled therapy services. There is no documentation that she requires services on an inpatient basis, only 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and skilled therapies at home or in a skilled 
nursing facility can be approved upon request. 
 
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 there is not a reasonable expectation that you would 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.
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 medically necessary for the enrollee to 
reach her maximum functional potential and to return home to her family. The Plan denied your request. The 
Plan says IRF care is not medically necessary and the rehabilitation physician noted the best option for the 
enrollee is to be at home with her daughter or in 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 that while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hydration therapy (code 96360) provided on January 3, 2022. 
 
You asked the Plan to pay for the hydration therapy. You say that this service was medically necessary. The 
Plan denied your request. The Plan says you did not bill this service with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that hydration therapy is only covered when billed 
with a covered diagnosis code.  In this case, you billed with diagnosis codes R22.21 and Z20.822.  Neither of 
these diagnosis codes is listed in the Medicare rules as a diagnosis that supports medical necessity for hydration 
therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hydration therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for hydration therapy (code 96360) provided on January 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
your condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 that you are an 80-year-old female with a past 
medical history of dementia, pulmonary embolus and peripheral arterial disease who was admitted to an acute 
inpatient rehabilitation facility on May 19 after treatment in an acute hospital for atrial fibrillation with rapid 
ventricular response. Based on the medical records provided there is no documentation that you require skilled 
nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not 
required to safely and effectively provide medically necessary and reasonable treatment. Records do not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care. 
While you require skilled therapy services, these services are not required on a daily basis. In conclusion, the 
acute inpatient rehabilitation facility you are currently in can provide for all of your present inpatient nursing 
and therapy needs. Continued care in the acute inpatient rehabilitation facility is appropriate until you are stable 
to transfer to home with home health care or to another 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established 
patient (92012) provided on January 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that you have been going to this clinic for many 
years and you want this service covered. The Plan denied your request. The Plan says this service is not 
covered because it was provided OON. 
 
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 ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, 
established patient (92012) provided on January 7, 2022, by an out-of-network (OON) provider.