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

 
We decided that the Plan does not have to pay for the home healthcare services provided on December 18, 
2021. 
 
You asked the Plan to pay for the home healthcare services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for date of service December 18, 2021, until January 25, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home healthcare services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home healthcare services provided on December 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you already paid, and now you have been asked 
to pay more. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 7, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transplant transportation and lodging expenses. 
 
You asked the Plan to pre-approve transportation and lodging expenses. You say that it can often take up to 90 
minutes for the enrollee to reach the clinic, so the lodging benefit would ensure the enrollee's safety during this 
critical period as well as meet requirements to reside within 30 minutes of the clinic for the treatment period. 
The Plan denied your request. The Plan says transportation and lodging is not covered because the transplant 
clinic is within the normal community patterns of care for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that plan must cover reasonable transportation and 
lodging (accommodations) for an enrollee and a companion when providing a transplant service at a distant 
location further away than the normal community patterns of care for that service.  
 
We looked at the file and Medicare rules. The requested transplant services are being performed within the 
normal community patterns of care for the enrollees service area; therefore, the Plan is not required to cover 
transportation and lodging expenses. Based on this information, we decided that Medicare rules for coverage of 
transportation and lodging expenses have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transplant transportation and lodging expenses.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for lab services provided on January 21, 2021.

You asked the Plan to pay for the lab services. You say that you did not have other insurance coverage on the date of service. The Plan denied your request. The Plan says that you had a primary insurer on this date of service.

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's sole rationale for denial of payment of this claim is that you had other insurance coverage as primary on this date of service.  However, the Plan has provided no evidence of other insurance coverage in the case file it sent to us.  In fact, the only evidence regarding different insurance is a letter to you from the alleged primary insurer that said that your coverage with them ended on December 31, 2020, which is prior to the date of service in dispute.  The Plan has failed to provide any documentation or proof in the case file that negates the information in this letter.  The burden is on the Plan to provide sufficient documentation to us to support its denial.  We find in this case that the Plan has failed to provide evidence of primary insurance coverage. Therefore, we decided that the Plan has to pay for lab services provided on January 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spine x-ray (72100) provided on May 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the spine x-ray. You say that although the treating provider is OON with the 
Plan, the enrollee cannot choose the radiologist who reads their diagnostic tests. You also say that you would 
like this claim to be reconsidered for payment. The Plan denied your request. The Plan says this service was 
rendered by an OON provider, and prior authorization was not 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the spine x-ray (72100) provided on May 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for 
LTACH admission and with the LTACH care they would receive they would be able to medically progress. 
The Plan denied your request. The Plan says the records do not show that the enrollee has a complex medical 
history. The records do not show that it is medically safe for the enrollee to go to an LTACH. When the 
enrollee is ready to leave the hospital, they can safely receive this care in another setting, such as a skilled 
nursing facility. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 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 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: 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 need rehab to help you to walk because you are 
not walking at the moment. You are scared to go home. You have an open wound on your arm and you also 
have pulmonary needs to be monitored because you were on dialysis and your kidney is failing. The Plan 
denied your request. The Plan says you do not meet criteria for IRF admission. 
 
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 you are functioning at a level that does not require intensive rehabilitation to recover. 
You are able to access the reasonable and necessary level of rehabilitation services without admission to an 
IRF. You have no complicated needs but standard post-acute needs. You do not require 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service October 21, 
2021. 
 
You asked the Plan to pay for procedure code 99024. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99024 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service October 21, 2021.
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 you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee fully meets the criteria for 
LTACH admission. The Plan denied your request. The Plan says the enrollee does not require long-term 
complex medications. The enrollee does not have complex wound care needs. The enrollee's medical plan 
needs can be met in their current setting. According to the records received, services that would be provided in 
the LTACH are being provided to the enrollee in their current health care setting. 
 
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 that there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 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 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 the LTACH services.
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 are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition, you do not mee the requirements for approval. 
 
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 you do not require treatment by multiple therapies, including either physical or 
occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a 
week, or fifteen hours over seven consecutive days. Occupational therapy notes dated September 20, 2022, 
indicated that you were contact guard assist for bed mobility and transfers. You are stand by assist for dressing. 
Physical therapy progress notes indicate that you ambulated 75 feet with minimal assist with a walker. You 
have had a functional decline from your baseline level of function and would likely benefit from therapy, but 
you do not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for bone imaging performed on December 1, 
2021. 
 
You asked the Plan to waive the copayment for bone imaging. You say that you should not be responsible for 
this copayment. The Plan denied your request. The Plan says the copayment has been applied 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 a $210 
copayment for covered diagnostic radiology services in the outpatient depart of a network hospital or facility.  
 
You have been asked to pay $210 for bone imaging. Bone imaging falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. 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 copayment 
for bone imaging performed on December 1, 2021.
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 are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says according to the available records, the 
enrollee does not meet all the required Medicare criteria for admission to an inpatient rehabilitation 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 there is no clinical documentation to show why the enrollee would require close 
medical supervision on an inpatient basis in an IRF as opposed to the current level of care in the skilled nursing 
facility in which the enrollee is making functional progress and is medically stable in. 
 
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 pre-approve the biologic materials (D4265) and the excision of 
benign lesion (D7410) for tooth #17. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental procedures done 
because you are in pain. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because biologic materials and excision of benign lesion are not covered by the Plan. 
 
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 pre-approve the 
biologic materials (D4265) and the excision of benign lesion (D7410) for tooth #17.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast reduction and mammapexy with re-insertion of a 
breast implant. 
 
You asked the Plan to pre-approve the reduction, mammapexy and implant replacement. You say that these 
surgeries should all be approved. The Plan denied your request. The Plan says the removal of the implant has 
been approved. The other requested services are not covered as they are considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that breast reconstructive services are not covered 
when provided in the situations described in the Medicare rules section. 
 
We looked at the file and Medicare rules. The reduction mammaplasty is being requested to improve 
appearance after implant removal. The mammapexy is not being provided after a Medicare-covered 
mastectomy. The initial implant placement was not performed due to the listed Medicare-covered indications, and as such, replacement is not covered either. Based on this information, we decided that Medicare rules for 
coverage of the reduction, mammapexy and implant replacement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve breast reduction and mammapexy with re-insertion of a breast implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the requested services. You say that the injection will provide the enrollee 
with pain reduction. The Plan denied your request. The Plan says this type of injection is considered 
experimental. 
 
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 requested services. Our physician 
reviewer found that the enrollee has septic arthritis. Genicular nerve blocks were requested to facilitate 
ambulation and pain control. This request is an experimental procedure to treat the pain associated with a septic 
joint. Therefore, the request is deemed not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.