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

 
We decided that the Plan does not have to pay for home health services provided from August 9, 2023, to 
September 7, 2023. 
 You asked the Plan to pay for the home health services. You say that all of the other claims for this patient 
were paid. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 11, 2023. The NOA was not received by the Plan until October 13, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 9, 2023, to September 7, 2023.
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 enrollee requires rehabilitation to build back their 
strength and coordination. The Plan denied your request. The Plan says the enrollee's condition does not meet 
the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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: 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 your current condition demands immediate intensive 
rehabilitation to regain your independence and restore your quality of life. The Plan denied your request. The 
Plan says your condition does not meet all the requirements for inpatient rehabilitation admission. The Plan 
also says services may 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall.  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 the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injections provided from 
January 13, 2023, to May 5, 2023.  
 
You asked the Plan to waive the coinsurance for the aflibercept injections. You say that you were not notified 
of changes made to your plan and the coinsurance should be covered. The Plan denied your request. The Plan 
says this cost sharing was charged 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.  
 
You have been asked to pay $318.57, which is 20% coinsurance of the allowed amount for each injection 
($1,592.85 allowed amount x 20% coinsurance = $318.57). You have been asked to pay a total of $955.71 ($318.57 coinsurance x 3 injections = $955.71). These services fall within the Medicare Part B prescription 
drugs 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 aflibercept injections 
provided from January 13, 2023, to May 5, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the immunization administration services described by code 90471 
billed on date of service September 30, 2022. 
 
You asked the Plan to pay for 90471. You say that 90471 should be paid as billed because it was coded 
accurately, and all required documentation has been provided. The Plan denied your request. The Plan says that 
90471 is denied because a fiscal intermediary rate letter is required and was not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that IHS providers were allowed to begin billing separately for Influenza, 
pneumococcal, and hepatitis B vaccines beginning January 1, 2006. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not provide a rule that clearly states why a fiscal 
intermediary rate letter is required for the immunization services in this case. Medicare rules indicate certain 
immunizations are not included in the AIR and may be billed separately by IHS providers. As such, we find 
that this service would not require a letter from the fiscal intermediary to allow payment. Therefore, we decided 
that the Plan has to pay for the immunization administration services described by code 90471 billed on date of 
service September 30, 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 pre-approve medical services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON medical services. You say that the enrollee requires this medical 
care. The Plan denied your request. The Plan says there is no reason given that the services cannot be provided 
by a network physician. It was confirmed that several network providers are able to schedule the enrollee in a 
reasonable time frame. 
 
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 
medical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram services described by code 95822 
performed on March 27, 2023, and March 28, 2023. 
 
You asked the Plan to pay for 95822. You say that 95822 should be paid as billed because it is supported in the 
medical record for both dates of service. The Plan denied your request. The Plan says 95822 is denied because 
it was not reported with the required modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that if the same physician or other supplier entity 
does not furnish both the TC and PC of the diagnostic service, the professional interpretation of a diagnostic 
test must be separately billed with modifier -26 by the interpreting physician.  
We looked at the file and Medicare rules. We confirmed that 95822 is a diagnostic service which has separate 
TC and PC. The claim was billed with place of service 21, indicating the enrollee received this diagnostic 
service in the inpatient setting, therefore, the same provider/supplier did not complete both the TC and PC for 
this service. According to Medicare rules, the provider performing the professional interpretation of the 
diagnostic service provided under arrangement to a hospital can bill and be paid for the PC of the service. The 
PC of a diagnostic service should be documented on the claim form with modifier -26. We have confirmed that 
95822 was billed without the required modifier -26. Based on this information, we decided that Medicare rules 
for coverage of 95822 have not been met. Therefore, we decided that the Plan does not have to pay for the 
electroencephalogram services described by code 95822 performed on March 27, 2023, and March 28, 2023.
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 would like to request reconsideration of the 
denied IRF services due to medical necessity. The Plan denied your request. The Plan says the IRF services 
you are requesting do not meet the requirements for approval.  
 
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 medically stable with no acuity or medical complexity and does not 
need physical medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No acute 
rehab skilled nursing needs identified or documented. 
The enrollee needs routine physical therapy and occupational therapy and does not need specialized intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. 
Document does not support necessity for admission to an IRF. The enrollees rehabilitation needs can be 
provided in an alternate and low intensity setting such as in a skilled nursing facility or continued services at 
home.  
 
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 an office visit provided on June 13, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 an office visit provided on June 13, 2023, by an 
OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs more time. The Plan 
denied your request. The Plan says continued care can be provided at another level of care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from September 15, 
2023, through December 23, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. 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 follows Medicare rules. Medicare rules say that power mobility devices are 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 a power scooter. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation notes a mobility 
deficit but does not indicate that the enrollee is unable to use a walker, wheelchair or cane to resolve this 
deficit. The documentation does not indicate the mobility deficit significant impairs MRADLs in the 
home. Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds 
(scooter) is not 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on July 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the reported diagnosis 
codes are not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. 
 
We looked at the file and Medicare rules. The claim in this case was billed with left-sided (M16.12) and right-
sided (M16.11) diagnosis codes. As a bilateral diagnosis code (M16.0) exists, it should be 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 the anesthesia services provided on July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20694 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for procedure code 20694. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says this code is packaged into the OPPS payment for this claim 
and is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that comprehensive APC 
payment policy packages payment for adjunctive items, services, and procedures into the most costly primary 
procedures under the OPPS at the claim level. When non-therapy outpatient department services are included 
on the same claim as a C-APC procedure (status indicator (SI) = J1), these services are considered adjunctive to 
the primary procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20694 have not been met. Specifically, this claim was submitted with code 25405, 
which has a status indicator of J1. Code 20694 has a status indicator of Q2, which means this service is 
packaged in this case. Therefore, we decided that the Plan does not have to pay for procedure code 20694 billed 
for date of service June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued consultation with an out-of-network (OON) 
otolaryngologist.  
You asked the Plan to pre-approve the OON otolaryngology services. You say that it is felt that continued care 
with the OON provider would be the best option. The Plan denied your request. The Plan says the Plan's 
network has providers of the same specialty who can assume the surveillance of the enrollee's dysplasia. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees 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 the OON otolaryngology services. Our 
reviewer says that the referral for continued OON care is not medically reasonable and necessary. Our 
physician reviewer found the record indicates that the enrollee has been undergoing surveillance for dysplasia 
of the tongue for over three years. The record provided does not document that the enrollee is currently 
receiving any active treatment of the condition. The elements of the coverage criteria are not satisfied. 
 
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 OON otolaryngology services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued consultation with an out-of-network (OON) 
otolaryngologist.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 18, 2022, to July 
17, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you are an in-network 
provider and there is a NOA on file. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 18, 2022. The NOA was not received by the Plan until September 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 18, 2022, to July 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 7, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the inpatient rate. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This 
provision applies to all hospitals, regardless of whether they are subject to PPS. 
 
We looked at the file and Medicare rules. Payment for the requested ambulance services is included in the 
inpatient fee rate. The ambulance services are not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance services provided on April 7, 2023.