Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a barrium swallow study provided on December 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for a barrium swallow study. You say that you would like this reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 a barrium swallow study provided on December 10, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation services provided on January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for observation services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 observation services provided on January 29, 2021 by an out-of-network (OON) provider.
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 is not medically necessary.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 an inpatient admission for a shoulder arthroplasty (23472).
You asked the Plan to pre-approve an inpatient admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the provided records do not show clinical information that would suggest you will likely have a prolonged hospitalization or have a significant increase in complication risk for the procedure. You are not expected to require hospital services that would likely cross 2 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a shoulder arthroplasty (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99239) provided on January 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 99239 is "Hospital discharge day management; more than 30 minutes". We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that more than 30 minutes of hospital discharge day management services were provided on the date of service in question. 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 the services (99239) provided on January 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits (G0299).
You asked the Plan to pre-approve additional home health skilled nursing visits. You say that these services are
medically necessary. The Plan denied your request. The Plan says the criteria for home health skilled nursing
services are not met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional home health skilled nursing
visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found
the enrollee is an 83-year-old male who is homebound with dementia. In this case, the enrollee does not have
any skilled nursing or therapy needs identified or documented. Skilled nursing services are not required to
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to
establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. In
addition, skilled therapy services are not required to effectively provide treatment, care, and/or services in order
to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the
patient's level of function and/or prevent deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional home health skilled nursing visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 14, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 14, 2021, forward. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from September 14, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 14, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 14, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 14, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 14, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 twelve (12) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been instructed in a home exercise program. The requested services are not part of a maintenance program, are
the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve twelve (12) additional PT visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 24, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the dental services. You say that your plan provides $1,000 annually for out-of-pocket dental expenses. You also say that your remaining balance is still $1,000 and you would like to be reimbursed. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective February 17, 2016, to February 17, 2022.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 24, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the PureWick External Female urine collection device.
You asked the Plan to pre-approve the PureWick External Female urine collection device. You say that this request is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 PureWick External Female urine collection device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the you are an 86-year-old female who has urinary frequency requiring 1-3 bathroom trips per hour. PureWick External Female urine collection device was requested. Based on the provided documentation, the patient is suffering and should not have to try an indwelling catheter or be bed confined to benefit from a low-cost, simple option to help her with her incontinence and urinary frequency. This device is appropriate and medically necessary for this patient as it would be safe and effective. 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 PureWick External Female urine collection device have been met. Therefore, we decided that the Plan has to pre-approve the PureWick External Female urine collection device.
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: 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 is not medically necessary.
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 do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 11, 2021, by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit (99212) and debridement (11721). You say that you do not agree
with the denial. The Plan denied your request. The Plan says you did not request prior authorization as
required.
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 services at issue in this appeal. The Plan did not pre-approve the
services 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 the office visit provided on March 11, 2021, by an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services and diagnostic imaging provided on
November 3, 2020, by an OON provider.
You asked the Plan to pay for specialist services and diagnostic imaging. You say that you would like this
claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained
by the member's primary care physician. The Plan says that there are in-network physicians available to
provide these services.
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 specialist services and diagnostic imaging
provided on November 3, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2020 by a nonparticipating
provider.
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 rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. There is no referring provider. 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 laboratory services
provided on March 5, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 28, 2020.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation (A0110) provided on September 23, 2020.
You asked the Plan to pay for non-emergency transportation. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code A0110 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergency transportation (A0110) provided on September 23, 2020.