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

 
We decided that the Plan does not have to pre-approve skilled-nursing services. 
 You asked the Plan to pre-approve skilled nursing. You say that the request is a medical necessity for you. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the available 
clinical documentation does not specify any acute clinical status changes, acute or worsening wounds, 
medication or plan of care changes. The records do not show that home health skilled nursing services are 
required to effectively provide treatment, care and/or services in order to improve your condition or to 
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled-nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the wig, any type (A9282) and non-covered item 
(A9270) purchased June 1, 2023 
 
You asked the Plan to reimburse you for the wig. You say that you are appealing the denial of your claim. The 
Plan denied your request. The Plan says this item is not covered under the Plan benefits. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig, 
any type (A9282) and non-covered item (A9270) purchased June 1, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aphasia assessment (96105) provided on August 07, 
2023. 
 
You asked the Plan to pay for the aphasia assessment (96105). You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the aphasia assessment 
(96105) provided on August 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
and related accessories (E0953, E1002, E1012, E1028, E2311, E2313, E2323, E2361, E2377, K0108, K0857). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power option and related 
accessories. You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for a Group 3 Single Power Option power wheelchair 
to be covered, there must be medical need for a special drive control (including, but not limited to, head 
control, sip and puff, switch control) or for a single power option: either power tilt or power recline. 
 
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 group 3 power wheelchair with a 
single power option and related accessories. Our reviewer says that this type of power wheelchair is not 
medically necessary. Our physician reviewer found the enrollee does not have high risk for skin breakdown, 
use a catheter intermittently, have spasticity or require an alternative means of managing power drive. There is 
no need for power tilt or power recline. Since the base power wheelchair is not covered, the requested 
accessories are also non-covered.  
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 group 3 power wheelchair with a single power option and related 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with a single power option and related accessories (E0953, E1002, E1012, E1028, E2311, 
E2313, E2323, E2361, E2377, K0108, K0857).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dual layer impax membrane, per square centimeter (Q4262) 
provided May 24, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 Q4262 is dual layer impax membrane, per square 
centimeter. 
 
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 service. Our reviewer found a request was made for dual layer impax membrane, per square centimeter (Q4262) provided May 24, 2023. However, although wound 
debridement was documented, the wounds were described as "improved" since the prior week with 
conservative treatment. Therefore, as the provided documentation did not sufficiently describe a failure of 
treatment of these wounds prior to application of the grafts, this request for the Impax membrane graft will be 
considered not medically necessary based on the provided documentation.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for dual layer impax membrane, per square centimeter (Q4262) provided May 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services (G0151, G0156). 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied home health physical therapy services due to medical necessity. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you have a 
past medical history of multiple medical comorbidities including osteoarthritis and a previous cerebrovascular 
accident with functional impairments. Clinical documentation does not provide a face-to-face provider visit, 
only a phone call visit. The records do not show that home health physical therapy services are required to 
effectively provide treatment, care, and/or services in order to improve your level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services (G0151, G0156).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 17, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services with the Outcome and Assessment 
Information Set (OASIS) billed for date of service April 25, 2023, to May 11, 2023. 
 
You asked the Plan to pay for the home health services with the OASIS billed.. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules say that a case-mix methodology adjusts the 30-day payment 
rate based on characteristics of the patient and his/her corresponding resource needs (e.g., diagnoses, functional 
impairment level, and other factors). The 30-day period payment rate is adjusted by a case-mix methodology 
based on information from home health claims, other Medicare claims, and data elements from the OASIS. The 
claims information and OASIS data elements are used to group 30-day periods of care into their case-mix groups. 
 
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 home health services with the OASIS 
billed. Our reviewer says that the OASIS billed is not supported. Our physician reviewer found the home health 
Registered Nurse, physical therapy and occupational therapy scored the enrollee with 0 and 1s for M1800 and 
M1810. As such, the billing of M1800 and M1810 with scores of 2 is not supported. Therefore, the OASIS 
billed is not supported. 
 
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 home health services with the OASIS billed. have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health services with the Outcome and Assessment 
Information Set (OASIS) billed for date of service April 25, 2023, to May 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy (G0151). 
 You asked the Plan to pre-approve additional home health services. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee has a past medical history of multiple comorbidities previously receiving home health services. 
Clinical documentation shows that the enrollee has met all appropriate home health physical therapy goals. The 
records do not show that 5 additional home health physical therapy visits are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a 
maintenance program to maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional home health physical therapy (G0151).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve continued home health occupational therapy visits (G0152 x19). 
 
You asked the Plan to pre-approve continued home health services. You say that the requested therapy is 
medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continued home health services. Our 
reviewer says that the services are medically reasonable and necessary. Our physician reviewer found the 
enrollee has a past medical history of multiple medical comorbidities previously receiving home health 
services. Clinical documentation shows that the enrollee has had both functional and clinical status change per 
provider documentation (worsening rheumatoid arthritis). It appears 19 units of home health occupational 
therapy services were denied due to lack of documentation as opposed to medical necessity. Clinical 
documentation shows that the enrollee requires increased amount of physical assistance with self-care tasks and 
mobility and is home-bound with occupational therapy goals of medical equipment and home safety evaluation. 
The additional home health occupational therapy units are required to effectively provide treatment, care, 
and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued home health services have been met. Therefore, we decided that the 
Plan has to pre-approve continued home health occupational therapy visits (G0152 x19).  
 
 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 pay for practitioner services provided on June 16, 2023, billed with 
procedure code 99203. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment has already been made for same/similar 
procedure within the set time frame. 
 The Plan must follow Medicare rules. Medicare rules say interpret the phrase new patient to mean a patient 
who has not received any professional services from the physician or physician group practice within the 
previous 3 years.  
 
We looked at the file and Medicare rules. We find that services have been provided by this physician group 
within the 3-year time frame. As such, the billed new patient code is inappropriate. Based on this information, 
we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on June 16, 2023, billed with 
procedure code 99203.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SIJ RFA. 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 sacroiliac joint (SIJ) Denervation (also called 
Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SIJ RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and 
therefore, not medically necessary. The review has determined that the requested SI joint RFAs are 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 SIJ RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sacroiliac joint (SIJ) radiofrequency ablation (RFA) (64625).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 1, 
2023, to April 26, 2023. 
 You asked the Plan to pay for SNF care. You say that you are not asking to go back in rehabilitation because 
your wounds have healed and youre working on rehabilitation. You are asking for reimbursement for the stay 
at the skilled nursing facility th9s care was medically necessary. The Plan denied your request. The Plan says 
there is no documentation or evidence of care that meets skilled nursing facility level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 you did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
required the specialized skill, knowledge, and judgment of a skilled professional therapist. You did 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 pay for skilled nursing facility (SNF) care provided from April 1, 2023, to April 26, 2023.
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 SNF services requested are medically necessary. 
The Plan denied your request. The Plan says the SNF services requested do not meet the requirements for 
approval. 
 
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 clinical documentation shows that the enrollee has had significant functional and 
clinical status change thus would be expected to require continued assessment by skilled nursing and skilled 
therapy. Clinical documentation with unclear past level of function currently requiring maximum assistance 
with functional mobility and self-care tasks. Therapy evaluations show that the enrollee was threatening 
physical violence to multiple staff members when attempting to work with the enrollee thus clinical 
documentation does not show that the enrollee would participate in daily skilled therapies. Documentation does 
not specify any daily skilled nursing needs (on oral antibiotics) and daily skilled services are not supported. As 
a practical matter, documentation does not justify daily skilled services on an inpatient basis in a skilled 
nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.