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 you believe that an IRF is necessary to regain 
maximum functions. You say that you need to maintain oxygen and have a continuous positive airway pressure 
machine for the rest of your life. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and you can safely receive the services 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on July 21, 
2022. 
 
You asked the Plan to pay for fixed partial denture sectioning (D9120). You say that prior to getting the bridge 
cut, you were told by the office staff that you would not have a charge for this service. The Plan denied your 
request. The Plan says procedures not listed on the Patient Charge Schedule are not covered and are your 
responsibility at the dentist's usual fees. 
 
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 fixed 
partial denture sectioning (D9120) provided on July 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from May 12, 
2022, to June 10, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, for all beneficiaries receiving HH services in 
2021 whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. The HHA 
should submit the artificial admission date on all subsequent claims until the beneficiary is discharged and 
another NOA is required. 
 
We looked at the file and Medicare rules. In this case, the admission date on the claim at issue does not match 
the admission date on the submitted NOA. 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 pay 
for home health services billed for dates of service from May 12, 2022, to June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 15, 
2021, to June 16, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee was admitted in stable condition and there was not a 
reasonable expectation that the care would need to span 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from June 15, 2021, to June 16, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not need skilled therapy services 5 days a week, does not need 
daily skilled nursing care, and can receive the care needed in another setting. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from August 10, 2022, to August 
11, 2022. 
 
You asked the Plan to pay for the medical services. You say that the medical records support payment. The 
Plan denied your request. The Plan says Original Medicare is responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 3, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided from August 10, 2022, to August 11, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the documentation does not show that your care cannot be provided at a lower 
level. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
encephalopathy and urinary tract infection. Your medical problems are stable, and you have are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. 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 August 25, 2022.
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 enrollee has no medical complexity, and no rehabilitation nursing needs other 
than routine nursing care. While the enrollee may benefit from physical therapy and/or occupational therapy,  
 the enrollee's rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for the office visit and allergy 
testing provided on July 18, 2022, and July 19, 2022, by out-of-network (OON) physicians. 
 
You asked the Plan to provide additional reimbursement for the OON office visit and testing. You say that you 
feel that the amount you were reimbursed for these services is very low. You do not feel that $3.34 is correct 
reimbursement when you paid $222 for this service. The Plan denied your request. The Plan says 
reimbursement was made based on the Medicare-allowed amount less 20% coinsurance. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans are only required to pay up to the 
Medicare-allowed amount for services rendered by OON providers. 
 
We looked at the file and Medicare rules. You were asked to pay more than the Medicare-allowed rate for these 
services. The Plan's obligation only requires payment for the Medicare rate. You may wish to request a refund 
from the providers if they are Medicare physicians. Based on this information, we decided that Medicare rules for coverage of the OON office visit and testing have not been met. Therefore, we decided that the Plan does 
not have to provide additional reimbursement for the office visit and allergy testing provided on July 18, 2022, 
and July 19, 2022, by out-of-network (OON) physicians.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 an Intracept procedure. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the intracept procedure is 
experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features of a leg prosthesis (L5962, L5968, 
L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for a K3 foot and extra cover does not meet the Medicare criteria for being 
reasonable and necessary. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that this patient is a K3 ambulator given his multiple 
comorbidities, need for a walker, and knee contracture. Additionally, the L5962 protective outer covering is not 
medically necessary per Medicare criteria. The documentation does not reveal that the patient will be exposed 
to harsh environmental conditions or engaging in activities that require protection beyond a standard cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional features of a leg prosthesis (L5962, L5968, L5981).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the requested services are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. 
 
The enrollee has remained medically stable without a recent hospital admission. She is medically stable and 
can receive further rehab services at a lower level of care.  Although further rehab services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. The enrollee does not have any complex wound care or 
nutrition given via a feeding tube.  She is medically stable without any acute exacerbations of chronic medical 
problems. Her physical function is at or near her baseline and she can receive services at a lower level of 
care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you disagree with the denial. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84436 and 84480 billed for date of service 
May 20, 2022. 
 
You asked the Plan to pay for procedure codes 84436 and 84480. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 84436 and 84480 is bundled into payment for 
code 84439. 
 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 codes 
84436 and 84480 are column II codes to column I code 84439. 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 84436 and 84480 billed for 
date of service May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that this provider will tell you if you need to 
go to the emergency room. You say that when you get the imaging done at this facility, the doctor sees the 
results right away. The Plan denied your request. The Plan says the MRI is available with a participating 
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 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. 
 
We looked at the file and the Plans rules. The file shows the requested provider in this case is not a network 
provider with the Plan. The Plan has network providers available who can provide the services at issue in this 
appeal. We found no exception that would require the Plan to pre-approve an MRI of the brain. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of the brain to be provided by an out-of-network 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 11, 2022, 
to February 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must report an additional line item with the 
same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the home health claim was not billed with the 
required Q code. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered 
from February 11, 2022, to February 24, 2022.