Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services represented 
by code 99239 provided on November 23, 2020. 
 
You asked the Plan to pay for code 99239. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 99239. 
 
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 Hospital 
discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent providing services to the enrollee on the day of discharge. The progress note for November 23, 2020 does not 
note how much time was spent providing services to the enrollee. As such, the provided documentation does 
not support the billing of CPT 99239. Based on this information, we decided that Medicare rules for coverage 
of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge day management services represented by code 99239 provided on November 23, 2020.
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 services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific 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 services are not medically necessary. Our physician reviewer found the enrollee has pain from lumbar
spondylosis. He underwent right-sided L3 to L4 and L4 to L5 steroid injections with 80 percent improvement
for three months. He had another steroid injection in April of 2021 that provided 70 percent pain relief. He has not had at least two two diagnostic medial branch blocks that each provided a consistent minimum of 80 percent pain relief. The RFA is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 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. You can receive further services at a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 23, 2021 by a non-
participating 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. 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 office visit provided on March 23, 2021 by a 
non-participating 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 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 the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says you have exhausted all of your rides. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used all of 
the rides for the year. Based on this information, we decided that the Plan's rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for 
additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2020. 
 
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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 19, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network dermatologist.  
You asked the Plan to pre-approve dermatology services. You say that you have been treated by this provider 
for 12 years and would like to continue with them, and this provider is an expert in MOHS surgery. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this provider 
is out-of-network with the Plan and you can be treated by an in-network dermatologist.  
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.   
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 dermatology services. Our reviewer 
says that you do not meet the Medicare criteria for a network exception for service with this out-of-network 
dermatologist. Our physician reviewer found there is nothing unique about your condition that would make it 
medically necessary to continue to see the requested out-of-network provider. The Plan's denial is medically 
justified on the basis that it is offering adequate ace to meet your medical needs through referral to an in-
network dermatologist. The Plan has shown that they have in-network provider who meet the standards of care 
required for treatment of your condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dermatology services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve dermatology services to be provided by an out-of-network dermatologist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility services. 
 
You asked the Plan to pre-approve the continued skilled nursing facility services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says continued coverage criteria has 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 the continued skilled nursing facility 
services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this 
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. The enrollee's ongoing needs can be met at a lower 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 the continued skilled nursing facility services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued skilled nursing facility services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on June 10, 2021. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says you must receive 
your care from a network provider. In most cases, care you receive from an out-of-network provider will not be 
covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network 
cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain 
authorization from the Plan prior to seeking care. In this situation, you will pay the same as you would pay if 
you got the care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies you received on June 9, 2021.
You asked the Plan to waive the coinsurance for the wound care supplies. You say that you don't understand why the Plan won't pay for these items in full. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for medical supplies. You have been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies fall within the medical 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 coinsurance for wound care supplies you received on June 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Keytruda injection you received on 
April 15, 2021. 
 
You asked the Plan to waive the coinsurance for the Keytruda injection. You say that you believe this 
coinsurance should be waived due to your financial circumstances. The Plan denied your request. The Plan 
says you were charged this coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs, including chemotherapy.  
 
You have been asked to pay 20% coinsurance for the Keytruda injection. The Keytruda injection falls within 
the Medicare Part B prescription drugs, including chemotherapy 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 coinsurance for the Keytruda injection you received on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.
You asked the Plan to pre-approve a motorized scooter. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane, or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the visit you had with a urologist on May 14, 2021.
You asked the Plan to waive the deductible for the urology visit. You say that you are being charged too much for this office visit. The Plan denied your request. The Plan says you were charged this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to specialist services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to specialist services. This cost sharing is a contractual obligation that had not been met at the time the urology visit was received on May 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the visit you had with a urologist on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9951).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D9951).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found a request has been 
placed for Aranesp to treat anemia in the setting of reported renal disease. There is no laboratory evidence of 
the enrollee's renal function. There is also no laboratory evidence of the enrollee's iron levels or evidence that 
low iron levels have been treated. There is no evidence that the enrollee is receiving chemotherapy or that the 
enrollee has myelodysplastic syndromes (MDS). 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does 
not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility services.