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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on December 12, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the submitted medical records support the ambulance transport services were medically 
necessary. The Plan denied your request. The Plan says our policy covers non-emergency ambulance 
transportation when it is the only way to safely and adequately transport a member or if other means of 
transporting a member are unsafe due to a medical condition. This claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 ambulance service, basic life support, 
non-emergency transport and ground mileage.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance to the emergency department was not medically necessary. The enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
LTACH admission, and their needs can be met at an alternative setting. 
 
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 that the enrollee appears to be more stable and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at a LTACH that are not already 
available at the current facility. 
 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer 
and as it would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on February 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you don't recall the last time you had the D0210 
intraoral - complete series of radiographic images service and believe the services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 6, 2019. 
Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of radiographic 
images (D0210) provided on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee currently meets LTACH admission criteria. The Plan denied your request. 
The Plan says the LTACH services requested do not meet the requirements for approval.  
 
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 improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on October 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 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 use of code 99223 is 
not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
comprehensive history. 
 
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 the services (99223) provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS-3D testing provided on April 21, 2022.  
 
You asked the Plan to pay for the WATS-3D testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of WATS-3D testing for screening, 
diagnosis or surveillance of cancerous or pre-cancerous esophageal lesions have not been demonstrated in the 
peer-reviewed literature.  
 
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 pay for the WATS-3D testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee's available record does not support the high likelihood of Barretts 
esophagus, and thus does not meet the spirit of the American Society for Gastrointestinal Endoscopy (ASGE) 
guidance relative to medically necessary use of WATS-3D in this case. 
 
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 WATS-3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS-3D testing provided on April 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes U0003 and U0004 billed for date of service January 
20, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the claim 
was denied correctly according to coding guidelines. 
 
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. 
 
In this case, the Plan denied services based on guidelines for respiratory pathogen panel testing. The records do 
not show that this type of testing is at issue in this case. The Plan has not denied the Covid-19 testing based on 
applicable rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for procedure 
codes U0003 and U0004 billed for date of service January 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 2, 2022, 
to November 6, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
evidence documented throughout the medical record clinically supports diagnosis code N39.0 and that the 
enrollee met the criteria for DRG 689. The Plan denied your request. The Plan says diagnosis code N39.0 is not 
supported, which resulted in a DRG change. 
 
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 with diagnosis code N39.0, defined as urinary tract infection, site 
not specified. 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 diagnosis code N39.0 is not supported. Our 
physician reviewer found the enrollee presented to the hospital with confusion, fatigue, sleepiness, and visual 
hallucinations in the setting of recent urinary tract infection (UTI) treated as outpatient. The workup revealed 
acute-subacute lacunar infarction. There was insufficient evidence of a UTI present during this admission.   
 
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 from November 2, 2022, to November 6, 2022, at the DRG originally 
billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 26, 2022, to August 
24, 2022. 
 You asked the Plan to pay for the home health services. You say that you sent in the required NOA. 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 July 26, 2022. The NOA was not received by the Plan until September 12, 
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 July 26, 2022, to August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and 
clearly exceeds the criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the Plan. 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: 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 do not feel it would be adequate to release the 
enrollee to a skilled nursing facility. You say if the enrollee got acute rehabilitation, they could get back to their 
everyday living. The Plan denied your request. The Plan says the IRF services requested 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain in this enrollee is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services billed for November 23, 2021, 
to November 24, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that the billing provider is not supported in the documentation. 
 
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. 
 
We looked at the file and the rules. The file shows that 23 pages of medical records were submitted, but the 
case file only includes 2 of the 23 pages. The records that were submitted show the rendering provider on the 
claim is noted in the records. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the evaluation and management services billed for November 23, 2021, to November 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4557 billed for date of service December 21, 2022. 
 
You asked the Plan to pay for code A4557. The Plan denied your request. The Plan says code A4557 is 
considered bundled and 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 procedure code.  
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
code A4557 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code A4557 have not been met. Therefore, we decided that the Plan does not have to pay for code A4557 
billed for date of service December 21, 2022.
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 will make measurable gains in an IRF.  
The Plan denied your request. The Plan says the enrollee's records do not show that they need an intensive team 
for their 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.