Persius/hicric huggingface dataset:
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 your legs are not strong enough to walk and you had 
a fall previously after being sent home. You say that while being in a skilled nursing facility you had fallen four 
times. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and you can 
receive the care you need in other settings. 
 
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 enrollee has chronic functional loss and has limited capacity to benefit from 
intensive rehabilitation. The enrollee does not require intensive rehabilitation services or frequent physiatry 
oversight. 
 
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 pre-approve a pneumatic compressor (E0651) and sleeve (E0667), to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and sleeve. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available that can 
provide this item. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0651) and sleeve (E0667), to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code (A6539).

You asked the Plan to pre-approve the compression stockings. You say that you have water blisters on your legs and the provider advised you that the velcro compression braces/hoses will help. The Plan denied your request. The Plan says the services denied correctly as they do not meet the clinical requirements to be approved.

The Plan must follow Medicare rules. The rules say that compression stockings described by code (A6539) are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code (A6539).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that multiple procedures were performed on this 
date. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341 x2).

You asked the Plan to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant. The Plan denied your request. The Plan says the services is not medically necessary.

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 periodontal scaling and root planing - four or more teeth per quadrant when the services are medically necessary and reasonable.

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 periodontal scaling and root planing - four or more teeth per quadrant. Our reviewer says that the service is not medically necessary.

Our physician reviewer found the documentation provided was not sufficient to make a determination if the criteria for coverage of the service have been met. There was no record of the charting of periodontal pockets and the radiographs were not of diagnostic quality to determine bone loss or subgingival deposits. The documentation provided does not meet the criteria for coverage for periodontal scaling and root planing (D4341) in the maxillary right and left quadrants.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing - four or more teeth per quadrant have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341 x2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 18, 2022 to 
April 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 18, 2022 to April 
16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can 
be treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 13, 2022 to 
March 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 13, 2022 to 
March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 03, 2022.

You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 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 an office visit provided on January 03, 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 enrollee requires therapy services due to a 
decrease in muscle strength, range of motion and coordination. The Plan denied your request. The Plan says the 
services needed can be safely fulfilled 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 enrollee does not require treatment by multiple therapies. The enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care 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: 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 a lower level of care cannot provide the total 
approach needed. The Plan denied your request. The Plan says the enrollee's condition requires further 
treatment in the acute care hospital. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for surgical repair of a patellar fracture and revision of 
knee arthroplasty. Her medical problems are stable.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. The complexity of the enrollees nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable neurostimulator (l8679), to be provided 
by a Naturopathic Physician. 
 
You asked the Plan to pre-approve the implantable neurostimulator. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit because the provider is not 
a Medicare approved practitioner. 
 
The Plan must follow Medicare rules. Medicare rules say that this diagnostic procedure which involves 
stimulation of peripheral nerves by a needle electrode inserted through the skin is performed only in a 
physician's office, clinic, or hospital outpatient department. Therefore, it is covered only when performed by a 
physician or incident to physician's service. If pain is effectively controlled by percutaneous stimulation, 
implantation of electrodes is warranted.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the implantable neurostimulator have not been met. Specifically, the records indicated you would 
be receiving this service through a Naturopathic Physician. Naturopath service are not covered under any 
condition. Therefore, we decided that the Plan does not have to pre-approve the implantable neurostimulator 
(l8679), to be provided by a Naturopathic Physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, airway inhalation treatment, albuterol, and ipratropium bromide provided on November 6, 2022.

You asked the Plan to pay for an office visit, airway inhalation treatment, albuterol, and ipratropium bromide. You say that this claim should be paid, and you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee must receive care from a network provider.

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 an office visit, airway inhalation treatment, albuterol, and ipratropium bromide provided on November 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70470 billed for date of service May 22, 2022.

You asked the Plan to pay for procedure code 70470. You say that these services are supported as billed. The Plan denied your request. The Plan says payment for code 70470 is bundled into payment for code 0042T.

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 have confirmed that code 70470 is a column II code to column I code 0042T. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70470 billed for date of service May 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you believe this provider is more qualified 
than the options recommended to you. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and you can be treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 8, 2021, to August 13, 
2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for inpatient care at the DRG originally billed. You say that these services and 
diagnoses were reported correctly and are supported as billed. The Plan denied your request. The Plan says that 
the DRG billed for this claim is not supported in the medical record. 
 
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. Specifically, the Plan has not forwarded the medical records used to make their 
decision. Without the medical records, we cannot verify whether or not the diagnoses at issue are supported for 
this inpatient admission. The Plan's denial is not supported by the case file provided. Therefore, we decided 
that the Plan has to pay for inpatient hospital services provided on August 8, 2021, to August 13, 2021, at the 
Diagnosis Related Group (DRG) originally billed.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
23, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are appealing this cost 
sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for each one-way Medicare covered trip.  
 
The enrollee has been asked to pay $120 for ambulance services. This amount is less than the standard 
copayment. This item/service falls within the ambulance services benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan.  
 
 
 
  
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the requested bed. The Plan denied your request. The Plan says the enrollee 
does not have a need for immediate changes in position. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed is covered under certain 
medical indications.  
 
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 requested bed. Our physician 
reviewer found that the enrollee has osteoarthritis. She reports sleeping in a recliner as she has trouble getting 
into bed due to it being too high. She is not bed bound and is able to walk, transfer, and shift weight in the bed. 
A request was made for a semi-electric hospital bed (E0261) in order to be able to adjust the height and to 
reduce risk of falling. Her condition does require position of the body in ways not feasible in an ordinary bed. 
She requires a lower height. the patient does not require frequent changes in body position once in the bed. 
There will not be a need for immediate changes in body position. Her condition does not require special 
attachments that cannot be fixed and used on an ordinary bed. A semi-electric hospital bed is not medically 
necessary for this enrollee based on the coverage criteria not being met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a semi-electric hospital bed.