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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
 
 You asked the Plan to pre-approve SNF services. You say that you need wound care that cannot be done at 
your residence. You say that your wound needs to be monitored to ensure that it is being cleaned properly and 
that the bandages are getting removed and replaced. You say that a rehabilitation facility is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs 
daily skilled therapy services. The Plan says that the enrollee does not have any daily skilled nursing needs. 
The Plan says that the enrollee's needs may be met at a lower level of care. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies or staff hours (99072) provided February 
12, 2021. 
 
You asked the Plan to pay for the additional supplies or staff hours. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this code is 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 CPT code. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this service has a status of "B" and payment is always bundled with another service. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies or staff hours have not 
been met. Therefore, we decided that the Plan does not have to pay for additional supplies or staff hours 
(99072) provided February 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from August 
23, 2021, to November 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were told the services would be 
accepted. The Plan denied your request. The Plan says the provider is not credentialed through Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider shall receive payment for services 
furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The records show that you received services from a licensed 
professional counselor. This type of provider is not eligible to participate in Medicare. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided 
from August 23, 2021, to November 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee can receive the care needed in another setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs.  Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs can be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided March 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like the hearing aids covered. The Plan 
denied your request. The Plan says the hearing aids are not covered because the provider is not part of the 
Plan's hearing aid vendor's network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you visit a provider in the Plans hearing aid vendors network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not purchased from a provider in 
the Plans hearing aid vendors network. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) provided March 31, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 18, 2021, to September 30, 2021. 
 
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 DRG and secondary diagnosis was not supported.  
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 689 (KIDNEY AND URINARY TRACT 
INFECTIONS WITH MCC). 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 services. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found the enrollee was admitted and treated for urinary tract infection, and exhibited confusion and 
poor memory. The records did not clearly describe the patient with toxic encephalopathy. Neurology suspected 
the patient might have underlying pseudo-dementia and/or vascular dementia contributing to symptoms. It was 
reported that confusion and memory issues had been present for more than 2 years. Therefore, based on the 
provided documentation, DRG 689 is not sufficiently supported and the more appropriate DRG would be 690.  
 
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 provided to the enrollee from September 18, 2021, to September 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and 
ground mileage (A0425) provided on September 23, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not under hospice on the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428), and ground 
mileage (A0425) provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam radiation therapy 
is preferable to intensity-modulated radiation therapy (IMRT). The Plan denied your request. The Plan says 
Proton beam radiation is not medically necessary for this patient's prostate cancer. There is no proven benefit of 
proton beam above IMRT for prostate cancer. 
 
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 proton beam radiation therapy. Our 
reviewer says that proton beam radiation therapy is not medically necessary. Our physician reviewer found that 
while proton therapy for prostate cancer is not experimental, any potential benefit or detriment of proton 
therapy over standard IMRT is an investigational question. Other treatment approaches (IMRT) are also highly 
effective and well tolerated.  Thus, whether proton therapy affords a benefit over other standard approaches 
(IMRT) for prostate cancer is an area of investigation and remains controversial. To date, there are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. So, in this case, medical literature recommends against routine use of proton 
therapy and there is little evidence that it is preferable over standard IMRT therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the intermittent catheter supplies (A4353) provided on December 3, 
2021. 
 
You asked the Plan to pay for the intermittent catheter supplies. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that the documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of 
delivery. 
 
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 Plan has denied coverage based on missing proof of delivery. In this case, after the Plan sent us the case 
file we received a valid proof of delivery. Therefore, we decided that the Plan has to pay for the intermittent 
catheter supplies (A4353) provided on December 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the complexity of the patient's nursing, medical and rehabilitation needs 
does not require an acute hospital stay with an interdisciplinary approach to rehabilitative care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of 
intestinal obstruction. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 25, 2021, 
through June 29, 2021, billed with secondary diagnosis code G93.41. 
 You asked the Plan to pay for the inpatient services as billed. You say that this was billed correctly as 
metabolic encephalopathy was clearly documented. The Plan denied your request. The Plan says the reporting 
of diagnosis G93.41 is not supported and inappropriately increased DRG payment. 
 
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 secondary diagnosis code G93.41, defined as 
metabolic encephalopathy. 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 
services as billed. Our reviewer says that the documentation does not support the use of the secondary 
diagnosis of G93.41 for this admission. Our physician reviewer found the review indicates that the 
documentation supported an admission for urinary tract infection. From the information that was received, 
documentation was inconsistent regarding a diagnosis of Metabolic Encephalopathy. Even though Metabolic 
Encephalopathy is documented on the Problem List, supporting medical record documentation was not found 
within the record. The member presented with fatigue and generalized weakness. 
 
Diagnosis of acute metabolic encephalopathy was not documented in discharge summary. Glasgow Coma 
Scale throughout the record scored 15. As noted above, although the provider documented metabolic 
encephalopathy, reasonable support within the health record must be present for that diagnosis. This was not 
found to be present.  
 
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 the inpatient hospital services provided from June 25, 2021, through June 29, 2021, billed with secondary 
diagnosis code G93.41.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on 
September 3, 2021. 
 
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 this was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
documentation did not support that the enrollee's condition was such that the time needed to transport a patient 
by ground or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. The documentation does not support that the transferring hospital did not have 
adequate facilities to provide the medical services needed by the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services provided to the enrollee on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the massage therapy (A9270) provided on May 
16, 2021, to June 18, 2021. 
 
You asked the Plan to reimburse you for the massage therapy. You say that our doctor recommended massage 
therapy to help with your lower back pain. You also say that this is not regular massage. The Plan denied your 
request. The Plan says massage therapy is not covered under the Wellness Allowance. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the massage therapy have not been met. Specifically, the file does not indicate that massage 
therapy is eligible for reimbursement under the Wellness Allowance. Therefore, we decided that the Plan does 
not have to reimburse you for the massage therapy (A9270) provided on May 16, 2021, to June 18, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0429) and ground mileage 
(A0425) provided on June 25, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
had shortness of breath because your inhaler did not supply the necessary relief. The Plan denied your request. 
The Plan says that the transportation was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and ground mileage. Our reviewer says that the ambulance 
transportation was medically reasonable and necessary. Our physician reviewer found you say that you were 
short of breath for 5 days despite inhaler use and called the ambulance on June 25, 2021 for transport to the 
emergency department. Our reviewer also found that your presenting symptoms met prudent layperson criteria 
for emergency 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 emergency ambulance transportation and ground mileage have been met. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on June 25, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health skilled nursing services (SNF) provided to the 
enrollee from August 2, 2021, to September 30, 2021. 
 
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 claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the denied services are not supported in the medical record. Specifically, it does not appear that the correct type of bill (TOB) was used in this case. 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 
home health skilled nursing services (SNF) provided to the enrollee from August 2, 2021, to September 30, 
2021.