Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for dialysis services provided out-of-area (OOA) on September 2 through 
September 30, 2022.  
 
You asked the Plan to pay for the OOA dialysis services . You say that the records provided support that the 
services in dispute were medically necessary. The Plan denied your request. The Plan says that the OOA 
services were not pre-authorized.  
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved 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 pay for the OOA dialysis services. Our reviewer 
says that the criteria for OOA coverage have been met.  Our physician reviewer found dialysis is a life 
preserving procedure.  The treatment could not be discontinued at the outpatient dialysis center safely and 
would have resulted in hospitalization.  There would have been increased morbidity and mortality on this 
patient in addition to wasteful costs to the healthcare system. 
 
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 OOA dialysis services have been met. Therefore, we decided that the Plan 
has to pay for dialysis services provided out-of-area (OOA) on September 2 through 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service September 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the testing is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab testing by a contract provider. The file does not show that the plan 
provided notice that the billed services would not be covered. Under Medicare rules, this means the billed 
services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab testing 
billed for date of service September 27, 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive physical and 
occupational therapy for strengthening. You say that an inpatient rehabilitation facility will assist the enrollee 
in a smooth transition back to the community. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 30, 2022, to 
July 29, 2022. 
 You asked the Plan to pay for the home health services. You say that you were confused about whether the 
Plan would be switching to NOAs, and you submitted the NOA late. 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 30, 2022. The NOA was not received by the Plan until November 14, 
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 the home health services 
provided from June 30, 2022, to July 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited appeal for the 
denial of a SNF admission based on medical necessity. The Plan denied your request. The Plan says the 
enrollee does not meet the medical necessity criteria for a SNF admission. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 4, 2022, to 
December 9, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided medical records and 
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 November 4, 2022. The NOA was not received by the Plan until March 17, 
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 December 4, 2022, to December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service November 23, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing billed for date of service November 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to receive physical therapy on an 
inpatient basis. You say the enrollee is very unstable on their feet, suffering from dementia and a very high risk 
for a bad fall. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
criteria for admission to a SNF.  
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot brace (L1932). 
 
You asked the Plan to pre-approve the ankle-foot brace. You say that the medical records support the need for 
the ankle-foot brace. The Plan denied your request. The Plan says the records show the enrollee is in a 
wheelchair and is minimal weight bearing. Per the criteria the ankle brace must be necessary for ambulation. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot braces may be covered for enrollees who 
meet coverage indications within certain categories. 
 
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 ankle-foot brace. Our reviewer says 
that there is no evidence of instability. Our physician reviewer found the enrollee has diabetes but does not 
have evidence of foot drop or an unstable ankle. 
 
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 ankle-foot brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ankle-foot brace (L1932).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee, molded socket, shin, sach foot, 
endoskeletal system (L5301) and an addition to lower limb prosthesis, multiaxial ankle with swing phase active 
dorsiflexion feature (L5968) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthetics. You say that there is only one provider in the enrollee's area and 
the referring physician does not want the enrollee to go there. The enrollee is very anxious to receive the 
prosthesis. The Plan denied your request. The Plan says the enrollee must use network provider for most 
services, unless there are emergency services, unforeseen urgent care or routine dialysis. The services are 
available with an in-network provider/supplier. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a below knee, molded socket, shin, sach foot, endoskeletal system (L5301) and an addition to lower limb 
prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) to be provided by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that medical necessity has not been 
established. The Plan denied your request. The Plan says the enrollee has failed conservative treatment without 
relief. 
 
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 an outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes and no facet 
joint syndrome or foraminal stenosis. Also, the cause of back pain is not clear.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99285 billed for date of service November 26, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on January 13, 2023. A comparison of the two claim lines shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for procedure code 99285 have not been met. 
Therefore, we decided that the Plan does not have to pay for 99285 billed for date of service November 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. The Plan denied your request. 
The Plan says this request does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 1 heavy duty power operated 
vehicle. Our reviewer says that you do not meet the coverage criteria for a power scooter. Our physician 
reviewer found you are noted to have difficulty ambulating and use a wheelchair. However, there is limited 
clinical information regarding your level of function with regards to mobility and why you cannot propel a 
manual wheelchair for mobility. Our reviewer found that there is limited documentation regarding your upper 
and lower extremity strength and range of motion. There is limited information regarding your ability to safely 
transfer to and from the requested power scooter and your ability to safely use it. Our physician reviewer also 
found that there is limited information indicating if your home is accessible for the requested power scooter. 
Therefore, the group 1 heavy-duty power mobility device 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 group 1 heavy duty power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 5, 
2022, through August 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with shortness of breath and 
palpitations following noncompliance with the Eliquis medication. The workup revealed an electrocardiogram 
sinus bradycardia with sinus arrhythmia, an incomplete right bundle branch block, and a computed 
tomographic angiography that was negative for a pulmonary embolism. Beta-blockers were held and other 
medications including Eliquis were restarted, and the enrollees heart rate improved. His vital signs were 
otherwise stable during the workup. Due to the low complexity and low severity of the enrollees condition 
around the time of the admission, which only required simple medication adjustment, it was not expected that 
the enrollee would require hospitalization that would likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from August 5, 2022, through August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2023, to 
February 7, 2023. 
 You asked the Plan to pay for the home health services. 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 January 9, 2023. The NOA was not received by the Plan until March 10, 
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 the home health services 
provided from January 9, 2023, to February 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 29, 2022, to 
August 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the NOA. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 29, 2022, to August 
27, 2022.