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

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) 
with prosthetic valve (33361). 
 
You asked the Plan to pre-approve the TAVR. You say that the enrollee is not a surgical candidate. You also 
say that the enrollee's only option for therapy would be TAVR. The Plan denied your request. The Plan says the 
records do not show that the enrollee has severe symptomatic aortic stenosis, for an FDA-approved indication, 
nor that the enrollee is participating in a clinical study for the use of TAVR for aortic regurgitation. 
 
The Plan follows Medicare rules. Medicare rules say that TAVR is covered for the treatment of symptomatic 
aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication. 
 
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 TAVR. Our reviewer says that the 
requested TAVR/TAVI is not medically necessary. Our physician reviewer found the provided documentation 
indicates severe aortic regurgitation, but only mild aortic stenosis. The reviewer found that mild aortic stenosis 
is not an FDA approved indication for the requested procedure. Therefore, the reviewer found that the 
requested TAVR is not medically reasonable or 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 the TAVR have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve (33361).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glucerna enteral formula. 
 
You asked the Plan to pre-approve the requested services. You say that this is the only alternative to keep the 
enrollee nourished. The Plan denied your request. The Plan says the service does not meet Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Glucerna enteral formula.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 1, 2022, to 
August 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says this could have been done as outpatient/observation. 
 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 acute inpatient hospital care. 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 underwent total left knee arthroplasty under spinal anesthesia 
without complication. The vitals were stable, and insulin, pain medication, and antibiotics were tolerated. The 
enrollee was promptly discharged home. It was not expected at the time of admission, that the enrollee would 
have required hospitalization that would have likely crossed 2 midnights based on the low complexity and low 
severity of the case. Observation status would have sufficed based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from August 1, 2022, to August 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 8, 2022, to August 
2, 2022. 
 You asked the Plan to pay for the home health services. You say that your organization has not received any 
payment for this period of care. 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 7, 2022. The NOA was not received by the Plan until August 5, 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 8, 2022, to August 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on February 6, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that this treatment was medically 
necessary for the enrollee with the dentist's referral. You also say that you would like this claim to be processed 
and paid. The Plan denied your request. The Plan says the submitted medical record does not include the 
assessment by the ordering provider. 
 
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 physical therapy services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record includes a referral from the dentist but no record of evaluation from the 
referring dentist. Our reviewer also found that the medical record should include an assessment of the enrollee 
by the ordering provider as it relates to the complaint of the enrollee for that visit. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the physical therapy services provided on February 6, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet all 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0428, A0425) provided on January 24, 2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says that this claim was submitted 
with incompatible diagnosis codes. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has indicated that this claim cannot be paid because it was 
submitted with diagnosis codes M84.48XA and S12.600A, which should not be reported together. However, 
the claim provided shows only diagnosis codes R45.851, T14.91XA, and Z78.9 were reported. The Plan has 
not provided a clear reason for denial which is supported by documentation in this case. The Plan's denial is not 
substantiated. Therefore, we decided that the Plan has to pay for ambulance services (A0428, A0425) provided 
on January 24, 2023.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for transplant related lodging, meals, and transportation (S9975) provided 
from November 9, 2022, to January 23, 2023. 
 
You asked the Plan to pay for transplant related lodging, meals, and transportation. You say that you had a 
kidney transplant in January 2023, and the live donor was a close friend who incurred quite a few travel and 
lodging expenses to do this surgery and have follow up appointments. You also say that you would like the full 
amount of the claim to be paid out. The Plan denied your request. The Plan says that the Health Plan will only 
cover travel and lodging for the enrollee and a companion. The Plan also says that per Medicare guidelines, 
travel expenses of the living donor are not allowable Medicare costs. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The rules allow for coverage of transportation services to the distant location and 
accommodations while in the distant location, for the enrollee and a companion. The Plan has not provided any 
evidence that coverage was supplied for transport and lodging for a different companion, which exhausted the 
benefit.  Therefore, we decided that the Plan has to pay for transplant related lodging, meals, and transportation 
(S9975) provided from November 9, 2022, to January 23, 2023.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the prosthetic implant (L8699) provided on November 3, 2021. 
 
You asked the Plan to pay for the prosthetic implant. You say that you were advised this is a coding error as the 
implant was a necessary part of the procedure. You also say that this should be covered. The Plan denied your 
request. The Plan says that this is not a covered service. 
 
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. 
 
You were referred for the prosthetic implant by a contract provider. The file does not show that the Plan 
provided notice that the prosthetic implant would not be covered. Under Medicare rules, this means the 
prosthetic implant is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
prosthetic implant (L8699) provided on November 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from October 26, 2021, to October 
27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the severity of presentation and treatment course did not warrant 
an inpatient stay. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee's presenting clinical scenario is consistent with necessary inpatient 
hospitalization with anticipated stay of over 2 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services rendered from October 26, 2021, to October 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 7, 2022, to July 29, 
2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
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 7, 2022. The NOA was not received by the Plan until January 26, 
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 July 7, 2022, to July 29, 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 if treated at a lower level, the enrollee would be at 
increased risk of morbidity, mortality, falls, and hospital readmission. 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 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 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0127-59) provided on March 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says modifier -59 is not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the use 
of modifier -59 is not supported by the records provided. Our physician reviewer found that the record does not 
state which nails were debrided and which were trimmed. It cannot be verified that the nails trimmed and 
reported with code G0127 were not the same as the ones debrided and reported with code 11720. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (G0127-59) provided on March 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on October 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99285 remains 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records had an 
appropriate history and physical, but they were not comprehensive, and more importantly, the records did not 
show medical decision-making of high complexity or problems that were severe enough to pose an immediate 
threat to life and/or function as the enrollee was stable and treatment was simple.  
 
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 emergency department services (procedure code 99285) rendered on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve collection and application of autologous blood 
concentrate product (D7921) and a bone graft (D6104). 
 
You asked the Plan to pre-approve collection and application of autologous blood concentrate product and a 
bone graft. You say that this should be covered. The Plan denied your request. The Plan says this is not a 
covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
collection and application of autologous blood concentrate product (D7921) and a bone graft (D6104).