Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and additional periapical
x-rays (D0230 x 4) provided on June 3, 2021.
You asked the Plan to pay for the dental services. You say that the enrollee was not able to have bitewing x-
rays because they did not have any upper teeth. The Plan denied your request. The Plan says periapical x-rays
are not listed as covered services.
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 periapical x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial
periapical x-ray (D0220), and additional periapical x-rays (D0230 x 4) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June
23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is
responsible to obtain prior authorization for all of their patients, which should also cover for the medical
treatments provided by this doctor. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.
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 domiciliary or rest home visit (99336)
provided on June 23, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nasogastric or orogastric tube placement (43752) provided
on June 10, 2021, by an OON provider.
You asked the Plan to pay for the outpatient procedure. You say that please review the attached records as you
will find the service provided was appropriate and medically necessary. The Plan denied your request. The Plan
says enrollee's must receive their medical services from an in-network provider with the exception being
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization
before services being rendered.
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 nasogastric or orogastric tube placement (43752)
provided on June 10, 2021, by an 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 you know you can handle 3 hours of therapy a day.
The Plan denied your request. The Plan says there is not a need for an intensive rehabilitation therapy program
consisting of at least 3 hours of therapy a day.
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 physician reviewer found
that you were admitted to the acute care hospital for surgical repair of an acetabular fracture after a fall.
Your medical problems are stable. You do not require treatment by multiple therapies in 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.
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 pay for medical services provided to the enrollee on July 9, 2021 and billed under code 70450.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing guidelines show and edit exists between codes 70496 and 70450. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, the claim cannot be paid as billed due to the omission of the appropriate modifier. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on July 9, 2021 and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be performed by an endodontist.
You asked the Plan to pre-approve the requested services. You say that your dentist does not do root canals.
The Plan denied your request. The Plan says there is no benefit for dental services performed by an
endodontist.
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.
We looked at the file, and Medicare rules. Covered dental services must be performed by a participating
general dentist. Based on this information, we decided that the Plan's rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pre-approve dental services to be performed by an
endodontist.
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. The Plan denied your request. The Plan says the enrollee is not
able to tolerate an intensive rehabilitation therapy program.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for weakness and a coronavirus infection. His medical
problems are stable. There is not a reasonable expectation that he will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF. While he has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that your records show you do not have need for daily skilled nursing nor daily skilled therapy.
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 that your condition does not meet Medicare criteria for SNF services. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed
tomography (CT) scan for attenuation.
You asked the Plan to pre-approve a PET/CT scan for attenuation. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET/CT scan for attenuation. Our
reviewer says that the services are not medically necessary. Our physician reviewer found CMS does not
provide PET imaging for initial staging for prostate cancer and thus the test would not be covered under current
guidelines.
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 PET/CT scan for attenuation have not been met. Therefore, we decided that
the Plan does not have to pre-approve a positron emission tomography (PET) with computed tomography (CT)
scan for attenuation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections.
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed medical management. The Plan denied your request. The Plan says the service does not meet the requirements for approval.
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 looked at the file and the rules. It appears that the codes requested are not consistent with the requested services. The file shows that the Plan made several attempts to get a correction and/or additional records with no response. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 9, 2021.
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 procedure codes 92978, 92979, and 93799 are not supported.
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 92978 is endoluminal imaging of coronary vessel or graft
using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation
and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List
separately in addition to code for primary procedure). The definition of code 92979 is endoluminal imaging of
coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during
diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report;
each additional vessel (List separately in addition to code for primary procedure). The definition of code 93799
is unlisted cardiovascular service or procedure.
We find that CPT codes 92978, 92979, and 93799 are not supported in the medical record. Specifically, there is
no documentation of an initial vessel endoluminal imaging of a coronary vessel or graft using IVUS or OCT to
support code 92978. There is no documentation of vessel endoluminal imaging of a coronary vessel or graft
using IVUS or OCT for each additional vessel to support code 92979. There is no documentation of an unlisted
cardiovascular procedure to support code 93799. 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 pay for the
surgical services rendered on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August
8, 2019, to August 18, 2019.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.
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 pay for the SNF care. Our reviewer says that the
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF setting.
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 SNF care have not been met. Specifically, the file shows that the enrollee
did not receive daily skilled care. Therefore, we decided that the Plan does not have to pay for the skilled
nursing facility (SNF) care provided from August 8, 2019, to August 18, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage to see a
urologist.
You asked the Plan to pre-approve additional routine mileage. You say that you need to see this doctor for a
cancer screening, and you do not trust other providers outside of this provider group. The Plan denied your
request. The Plan says your routine transportation benefit is limited to 75 miles of driving distance per trip. The
requested location exceeds 75 miles of driving distance, and there are urologists closer to you who can provide
the necessary care.
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. The Plan covers routine transportation when the services are provided via ground transportation to or
from Plan-approved locations. Each one-way trip must not exceed 75 miles of driving distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. The requested location is further
than 75 miles away. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation mileage to see a urologist
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 your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 reduction and external fixation of bi malleolar fracture after a fall. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that 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 that you were admitted for diabetic ketoacidosis and new onset diabetes and was discharged to skilled nursing on December 14, 2021. 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. In conclusion, 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. 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: Home Health
Decision: Favorable

We decided that the Plan has to pay for the physical therapy (PT) services provided from July 20, 2019, to September 16, 2019.
You asked the Plan to pay for the PT services. You say that you would like this claim to be reconsidered because the patient was home bound and needed home health services. The Plan denied your request. The Plan says that the documentation does not contain a physician's order to support the physical therapy services that were billed.
The Plan must follow Medicare rules. Medicare rules say that the orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as the home health aide (HHA) personnel who receive the oral orders notify that nurse or therapist before the service is rendered. We looked at the file and Medicare rules. The records show that the second order for physical therapy services to be provided twice weekly beginning August 18, 2019 was signed by the physical therapist on August 14, 2019. It appears that the order was initially given verbally as well, and the order was signed by the doctor on August 26, 2019. Based on this information, we decided that Medicare rules for coverage of the PT services have been met. Therefore, we decided that the Plan has to pay for the physical therapy (PT) services provided from July 20, 2019, to September 16, 2019.
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.