Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for individual psychotherapy (90832) provided August 10, 2021.

You asked the Plan to pay for the psychotherapy. You say that please review complete medical record. The 
Plan denied your request. The Plan says that the listing of a referring provider on the claim does not satisfy the 
documentation criteria.

The Plan must follow Medicare rules. Medicare rules say that if the patient consents, you must attempt to 
consult their attending or primary care physician about provided services and either document consent or 
declination date to consultations and date of consultations in patient's medical record. This does not apply if 
the physician referred the patient to the clinical psychologist. 

We looked at the file and Medicare rules. The submitted claim includes a referring provider for the services at 
issue. Documentation of a physician consultation does not apply when the physician has referred the 
beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage 
of the psychotherapy have been met. Therefore, we decided that the Plan has to pay for individual 
psychotherapy (90832) provided August 10, 2021.

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 pay for ambulance response and treatment, no transport (A0998)
provided on May 13, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your lower body
was paralyzed after falling out of your wheelchair and you needed to call 911 because no one else was home
and you believe that the insurance should cover the services because you were on the floor with no assistance.
The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and
without a transport there is no payable service.
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 May 13, 2021. 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 ambulance response and treatment, no transport
(A0998) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 3, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation -
new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided
October 5, 2021, by an OON provider.
You asked the Plan to provide additional payment for the comprehensive oral exam and complete series of x-
rays. You say that you were not made aware that the provided was not in the Plan's network. The Plan denied
your request. The Plan says the claims processed correctly according to your OON benefits.
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
comprehensive oral exam and complete series of x-rays with 50% coinsurance when provided OON.
Additionally, you may be billed by the OON provider for any amount greater than the payment made by the
Plan to the provider.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that your
coinsurance was correctly applied as 50% of the allowed amount for both services. Additionally, you are
responsible for the difference between the Plan's contracted allowed amount and the total amount billed by the
OON provider. Therefore, we decided that the Plan does not have to provide additional payment for the
comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of
radiographic images (D0210) provided October 5, 2021, by an OON provider.
Your complaint about feeling that you were not properly informed of the provider's out-of-network status is
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 5, 2021, by an out-ofnetwork (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on August 5, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and
management of an established patient (99336) rendered by the OON provider on August 17, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network
provider, without prior authorization.

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 in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99336) rendered by the OON provider on August 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from October 19, 2021,
through October 28, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the Plan.
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 did not pre-approve the
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physical therapy services provided from October 19, 2021,
through October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from August 9, 2021,
through September 6, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services was not medically 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 pay for continuation of SNF services provided from
August 9, 2021, through September 6, 2021. Our reviewer says that daily skilled services are not medically
necessary. Our physician reviewer found based on the medical records provided there is no documentation that
the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled
professional nurse were not required to safely and effectively provide medically necessary and reasonable
treatment from August 9, 2021, through September 6, 2021. This enrollee did require part time skilled therapy
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were required to safely and
effectively provide medically necessary and reasonable treatment from August 9, 2021, through
September 6, 2021. Daily skilled services were not required from August 9, 2021, through September 6, 2021.
As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing
facility setting. The provided records did not document a need for daily skilled services in a skilled nursing
facility from August 9, 2021, through September 6, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services provided from August 9, 2021, through
September 6, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for
continuation of SNF services provided from August 9, 2021, through September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle orthosis (L1902) rendered by the OON provider on
September 28, 2021.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial
for payment. The Plan denied your request. The Plan says this item was rendered by an out of network
provider, without prior authorization.

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 in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.
We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan
does not have to pay for the ankle orthosis (L1902) rendered by the OON provider on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on April 13, 2021, by an out-
of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you say that you are appealing with supporting
records. The Plan denied your request. The Plan says the rendering provider is a non-participating provider, and
the referring provider involved in these services is a non-participating provider with the Plan. The Plan also
says that they did not authorize any services for these providers.
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 drug testing (G0482) provided on April 13, 2021,
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management analysis coded 0117U provided on March 24, 2021.  You asked the Plan to pay for the pain management analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  Review of the file shows that there is no documentation by the ordering physician stating how the rendered testing will directly impact the enrollee's treatment plan. This means that the pain management analysis at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the pain management analysis coded 0117U provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from January 30, 2021, through 
February 9, 2021, with the reported principal diagnosis J96.01, Acute respiratory failure with hypoxia.

You asked the Plan to pay for inpatient services provided from January 30, 2021, through February 9, 2021,
with the reported principal diagnosis J96.01, Acute respiratory failure with hypoxia. The Plan denied your 
request. The Plan says that the Plan does not dispute that the member utilized supplemental oxygen post 
operatively; however, your letter failed to address that there was documentation of persistent respiratory 
distress/increased work of breathing; persistent tachypnea (rate greater than 24), cyanosis or persistent or 
progressive dyspnea during the hospital stay to meet the criteria for acute respiratory failure. The physician 
documented in the progress notes that the member was in no respiratory distress.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.
 
In this case, you billed the inpatient services provided with the principal diagnosis J96.01, Acute respiratory 
failure with hypoxia. 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 inpatient services provided 
with the reported principal diagnosis J96.01, Acute respiratory failure with hypoxia. Our reviewer says that the 
documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that 
no blood gasses were found in documentation submitted. Oxygen saturation on January 30, 2021 was 95% at 
14:07 on room air, January 30, 2021 at 12:59 96% (no documentation of room air or oxygen), January 30, 2021 
at 11:19 96% (no documentation of room air or oxygen), January 30, 2021 at10:53 (no documentation of room 
air or oxygen). Respiratory complications documented on February 2, 2021 showed that the enrollee was put 
on oxygen via nasal cannula. Throughout hospital admission SP02 remained above 90% on oxygen. After 
oxygen administered, no further respiratory complications were documented. In this case due to lack of clinical 
indicators/criteria, the physician should be queried for clarification.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from January 30, 2021, through February 9, 2021 with the reported principal 
diagnosis J96.01, Acute respiratory failure with hypoxia.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 radiofrequency ablation.
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 procedure is not supported at the same levels as anterior lumbar interbody spinal fusion.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is documented that the enrollee has previously undergone five spinal fusions, but the surgeries performed are not specified. The rules say that facet joint procedures performed after anterior lumbar interbody fusion are not considered medically reasonable and necessary, and will therefore be denied. There is insufficient information to support that this coverage criterion has been met 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an EGD provided on May 28, 2021.
You asked the Plan to pay for an EGD. The Plan denied your request. The Plan says the member needs to see
providers that are in network for the services to be covered. The Plan covers urgent or emergent for out of
network providers unless a preauthorization is approved. This service was not urgent or emergent.
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 did not pre-approve the
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an EGD provided on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar spinal fusion.
You asked the Plan to pre-approve these services. You say that you need surgery because of the intense pain. The Plan denied your request. The Plan says that your provider's documentation indicates that you should continue with conservative treatments to determine if there will be improvements in your symptoms.
The Plan must follow Medicare rules. Medicare rules say that a lumbar spinal fusion may be covered if the LCD criteria are met. 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The records show previous L1-4 instrumented fusion. There is no documented instability, fracture, or lesion below the previous surgery. Our physician reviewer found that your condition does not meet criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a lumbar spinal fusion.