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

 
We decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to 
April 12, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The 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. 
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the NOA is not a 
one-time, artificial 'admission' date corresponding to the "From" date of the first period of continuing care in 
2022. 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 14, 2022, to April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair initial incisional or ventral hernia; reducible provided 
to the enrollee on January 31, 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 CPT 49560 is considered inclusive to CPT 44625. 
 
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 49560 is "Repair initial incisional or ventral hernia; 
reducible." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee with a history of 
colon perforation was status post ileostomy who underwent a take down ileostomy closure on 1/31/22. The 
patient had a parastomal hernia at the ileostomy site which was the same incision as the ileostomy takedown. 
The hernia was within the same open incision as the ileostomy closure which is not considered a separate and 
distinct procedure. The operative report does not support CPT 49560 as a separate and distinct procedure from 
CPT 44625. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for repair initial incisional or ventral hernia; reducible provided to the enrollee on January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95867) provided on January 
19, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the service was necessary for the enrollee. 
The Plan denied your request. The Plan says the service in this case is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that there are certain diagnosis codes that support the 
medical necessity of EMG. 
 
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 outpatient service. Our reviewer says 
that the needle electromyography was not medically necessary. Our physician reviewer found a needle 
electromyography (95867) was provided on January 19, 2022, to this enrollee as part of intraoperative 
monitoring during a tumor resection to help minimize collateral damage during the resection. Based on the 
Local Coverage Determination (LCD) criteria for EMG testing, the enrollee does not meet any of the 
indications or clinical situations. 
 
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 outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pay for the needle electromyography (95867) provided on January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
September 19, 2022, and an inpatient hospital stay from September 19, 2022, to September 23, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation and an inpatient hospital stay. You 
say that you are on disability and now have to pay 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). Your contract with the Plan clearly says that you must pay $250 for 
each one-way Medicare-covered ambulance transport. Your contract with the Plan also clearly says that you 
must pay $325 per day for days 1 to 6; $0 for additional hospital days. 
 
You have been asked to pay $250 for ambulance transportation. This item/service falls within the ambulance 
transportation benefit category. You have also been asked to pay $1,300 ($325 x 4 = $1,300) for an inpatient 
hospital stay. This item/service falls within the inpatient hospital care benefit category.  The amount you owe is $1,550 ($250 + $1,300 = $1,550). This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for ambulance transportation provided on September 19, 2022, and an inpatient hospital stay from September 
19, 2022, to September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on June 30, 2022. You asked the Plan to pay for the office visit. You say that this service is supported as billed. The Plan denied 
your request. The Plan says the payment for this service is included in the 90-day global surgery package for 
code 66984, which was provided to this enrollee on May 5, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures 
with a global surgery period includes payment for following services related to the surgery when furnished by 
the physician who performs the surgery.  
 
We looked at the file and Medicare rules. The service at issue is an evaluation and management service which 
was performed within the 90-day global surgery period of code 66984. Both codes were billed by the same 
physician for the same enrollee. Code 99213 was not billed with a modifier, nor was supporting documentation 
provided to show that this service is not related to the enrollee's recent procedure. Based on this information, 
we decided that Medicare rules for separate payment of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213) provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Treatment (PBT). 
 
You asked the Plan to pre-approve PBT. 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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in summary, proton therapy is not experimental, but rather is simply another means if 
delivering radiation, and has been in use for the treatment of oncology patients for decades. There are 
dosimetric advantages to using proton therapy over Intensity modulated radiation therapy (IMRT) in select 
situations, in which proton therapy offers a clinically meaningful benefit. For this enrollee there is no plausible 
reason for why IMRT would be unacceptable or that proton therapy would offer a plausible clinically 
meaningful benefit over standard of care IMRT. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Treatment (PBT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 there is no documentation that you require the services on an inpatient basis, only in a 
SNF setting. Records support the services in the long-term care facility on a part time basis are appropriate in 
this case. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the initial injection provided improvement for 
three weeks at 50%. You say that the enrollee was able to improve their function during that time. You also say 
that the requested ESI is medically necessary. The Plan denied your request. The Plan says a repeat ESI is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the medical record documentation does 
not reveal at least 50% sustained improvement in pain relief and/or improvement in function measured from 
baseline using same scale for at least three months from prior injection on September 9, 2022. Therefore, the 
reviewer found that a repeat ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (64483).
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 the enrollee still needs skilled nursing. The Plan 
denied your request. The Plan says the denial of authorization for continued skilled nursing facility (SNF) care 
is correct. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
February 27, 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 the records do not support the services billed. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not support the presence of a separate monitoring practitioner. There is no separate sedation record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services provided to the enrollee on February 27, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was evaluated in the Emergency Department on 12/26/22 and discharged 
home. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does 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 this 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.
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 you have has gone without therapy for 
approximately 3-4 weeks and your legs and lower extremities are becoming very rigid and stiff causing a 
considerable amount of pain. You were walking with a walker 4 weeks ago at another rehab unit and then 
moved to an assisted living where you can only get one day of therapy per week. The Plan denied your request. 
The Plan says your records show that it is not reasonable to expect you to improve in a reasonable amount of 
time. Your records do not show active medical conditions and the services you need can be provided safely in 
other settings, for example, a residential care facility, or home with home health services. 
 
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 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 safely 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 inpatient rehabilitation facility (IRF) admission and services.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 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 pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 1, 2022 to September 9, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says only 7/23/22 - 7/31/22 can be allowed based on the enrollee's COVID-19 status. 
 
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 pay for 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 that there were no identifiable skilled nursing or skilled therapy needs. The enrollee 
did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from August 1, 2022 to September 9, 
2022.