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

 
We decided that the Plan does not have to pay for the home health skilled nursing services provided on July 29, 
2022, to August 18, 2022. 
 
You asked the Plan to pay for home health skilled nursing services. You say that the medical records provided 
support the need for the skilled nursing services. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found the documentation 
doesn't support that the enrollee required additional skilled nursing services to provide treatment that was 
medically necessary. The enrollee did not require additional skilled nursing services to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. The enrollee had been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health skilled nursing services provided on July 29, 2022, to August 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on August 25, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this service is included in 
the global period for code 20611. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. The requested service (99213) is included in the global surgery 
period for the procedure (20611) provided on the same date of service. Based on this information, we decided 
that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) provided on August 25, 2021.
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. The Plan denied your request. The Plan says the 
enrollee can remain in the current acute care location until such time no further acute level care is needed, 
discharge to a lower level of care would not be appropriate with ongoing acute care needs, medically necessary 
care may be provided safely in a lower level of care. 
 
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 is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6240), and a retainer crown (D6750). 
 
You asked the Plan to pay for a pontic (D6240) and a retainer crown. You say that this dental work is 
medically necessary. The Plan denied your request. The Plan says the requested dental work has been correctly 
denied. 
 
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. The Plan covers a pontic 
(D6240) and a retainer crown when the services are medically necessary and reasonable.  
 
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 a pontic (D6240) and a retainer crown. Our 
physician reviewer found the documentation provided does not meet the criteria for coverage for a fixed bridge 
replacing tooth #3 with a pontic using teeth #'s 2 and 4 as abutment retainers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic (D6240) and a retainer crown have not been met. Therefore, we 
decided that the Plan does not have to pay for a pontic (D6240), and a retainer crown (D6750).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that experimental 
services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. It should also be noted that the Plan made a denial based on medical necessity, but did 
not submit medical records from the contracted provider. Therefore, we decided that the Plan has to pay for the 
lab services provided on April 7, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on May 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the medical records 
submitted do not include medical records for the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
submitted documentation does not contain medical records for the billed date of service. Therefore, we decided 
that the Plan does not have to pay for the services (99233) provided on May 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and related accessories to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and related accessories. You say that the items at issue 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
OON services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and related accessories to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient dialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient dialysis services. You say that the requested services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not 
separately covered when the enrollee resides in a skilled nursing facility (SNF). 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve outpatient dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint Pain Nerve Stimulation system (L8680, 64555). 
 
You asked the Plan to pre-approve the Sprint Pain Nerve Stimulation system. You say that this device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Sprint Pain Nerve Stimulation 
system. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this device is considered experimental for shoulder pain. More research 
is needed to show safety and efficacy. 
 
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 Sprint Pain Nerve Stimulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Sprint Pain Nerve Stimulation system (L8680, 64555).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital with left sided weakness, and difficulty 
speaking. On review of the available records, the enrollee with history of transient ischemic attach (TIA) does 
not meet coverage criteria for IRF admission. The enrollee is medically stable with no new or other acute 
medical problems or events, does not need a physician's supervision three times a week in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the spinal canal 
and contents, lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has low back pain with radiculopathy. The record provided does not indicate the 
presence of red flag signs or symptoms or the failure of conservative management including physical therapy. 
The requested service is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of the 
spinal canal and contents, lumbar; without contrast material (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liver support with milk thistle supplement provided on 
November 2, 2022. 
 
You asked the Plan to pay for the liver support with milk thistle supplement. You say that this should be 
covered under your over-the-counter (OTC) medications. The Plan denied your request. The Plan says the 
service was not a covered benefit. 
 
Medicare generally does not cover OTC medications. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the liver support with milk thistle 
supplement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the liver support with milk thistle supplement provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the electrodes. We decided that the Plan does not have to pay for the 
electrical stimulator.  
 You asked the Plan to pay for the electrical stimulator (E0730) and electrodes (A4595) provided on October 
19, 2022. You say that the items should be covered. The Plan says that the provided documentation did not 
sufficiently support the billed supply code. 
 
We decided that the Plan has to pay for the electrodes.  
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Therefore, we decided that the Plan has 
to pay for the electrodes.  
 
We also decided that the Plan does not have to pay for the electrical stimulator. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the date of service in this case. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulator. 
 
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 pay for inpatient hospital services rendered from June 4, 2022, to 
June 8, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically, and the DRG 
was updated. 
 
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 DRG 872. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not indicate that the treatment ordered by the treating medical providers supported 
a diagnosis code of A41.9 (Sepsis, unspecified organism). The laboratory studies showed an elevated white 
blood cell (WBC) count of 18.1 with normal platelets, creatinine and bilirubin. She was treated medically and 
improved. There was no evidence of life-threatening organ dysfunction due to dysregulated host response to an 
infection or persistent hemodynamic instability. In this case, the documentation does not consistently and 
completely support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis 
code and adjust the DRG is upheld.  
 
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 hospital services rendered from June 4, 2022, to June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
April 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support the level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documented history is not 
comprehensive.  The record noted post-operative hypoxia but made no attempt to differentiate a cause 
(infection, aspiration, medication) or address co-morbidities. While the enrollees condition appears to have 
been moderate/severe, the medical decision making was problem focused. As such, the billing of CPT 99223 is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power 
option (K0858), electrical connection between the wheelchair controller and two or more motors (E2311), 
expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and a joystick.. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for these items to be covered, the criteria in the 
Medicare Rules section must be 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 a group 3 power wheelchair with single 
power option and a joystick. Our reviewer says that these items are not medically necessary. Our physician 
reviewer found the documentation does not indicate that the member has any pressure injuries or requires 
intermittent catheterization of the bladder that would necessitate power tilt or recline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with single power option and a joystick. have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 3 
standard, single power option (K0858), electrical connection between the wheelchair controller and two or 
more motors (E2311), expandable controller (E2377) and harness (E2313).