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

 
We decided that the Plan does not have to make additional payment on the clinic and x-ray services billed on 
December 7, 2022. 
 
You asked the Plan to make additional payment on the services billed on December 7, 2022. You say that the 
bill you received from your provider is significantly higher than any other services you received from the same 
provider, therefore additional payment should be made. The Plan denied your request. The Plan says the 
request for additional payment is denied because the provider has confirmed the claim was billed incorrectly 
and they will resubmit the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept payment in 
amounts applicable in Original Medicare as payment in full. 
 
We looked at the file and Medicare rules. We have confirmed the Plan made the correct payment for the 
services on December 7, 2022, as billed. If the billing provider is a Medicare provider, they are required to accept this payment as payment in full for the services at issue and should not bill you for amounts exceeding 
the allowable. Therefore, we decided that the Plan does not have to make additional payment on the clinic and 
x-ray services billed on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4239 for date of service January 16, 2023. 
 
You asked the Plan to pay for code A4239. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that E11.9 has an Excludes1 note in relation to E10.65. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for code A4239 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A4239 for date of service January 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service February 1, 
2022, to February 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until March 31, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the home health services for date of service February 1, 2022, to 
February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthesis (L5984, L5988). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation to show the need for these items. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items do not describe a complete foot. There is no documentation from the enrollee's 
physician that supports the need for these items. The requested items exceed the enrollee's needs.  
 
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 pre-approve a new prosthesis (L5984, L5988).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health physical therapy (PT) visits and 4 home 
health aide visits. 
 
You asked the Plan to pre-approve the PT and home health aide visits. 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. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 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 PT and home health aide visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
clinical documentation provided does not provide any care plan in which the assistance of a skilled home health 
aide would be required. The documentation does not support that 4 home health aide visits are medically 
necessary. The requested services cannot be approved. 
 
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 PT and home health aide visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 home health physical therapy (PT) visits and 4 home health aide 
visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing (G0299 x8) and home 
health aide (G0156 x17). 
 You asked the Plan to pre-approve home health services. 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. 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 the clinical 
documentation does not specify any new/acute medical concerns, changes in medications or plan of care; 
thus, the records do not show that 8 home health skilled nursing visits are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee is 
documented to be standby assist with activities of daily living (ADLs) and without home health skilled nursing 
there is no documented medical necessity for continued home health aide services; thus, 17 additional home 
health aide visits are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health skilled nursing (G0299 x8) and home health aide (G0156 x17).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing (G0299 x6). 
 You asked the Plan to pre-approve home health services. You say that the service is 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any unmet home health skilled nursing goals, new/acute medical concerns, 
changes in medications or plan of care thus the records do not show that 6 home health skilled nursing visits 
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, 
or to establish/perform a maintenance program to maintain the enrollee's 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health skilled nursing (G0299 x6).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heart catheterization (93458). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a recent radionuclide stress test which was negative for ischemia. The rationale 
for this invasive study is not clear. Guidelines do not support a need for cardiac catheterization in this setting. 
As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in 
this enrollee's clinical management.  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the heart catheterization (93458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device at L4-L5. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that this procedure would 
help treat the enrollee's spinal stenosis. The Plan denied your request. The Plan says this procedure has not 
been proven to benefit the treatment of the enrollee's health problem. 
 
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 a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex device is experimental, and more research is 
needed. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device at L4-L5.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 for date of service June 12, 2023. 
 
You asked the Plan to pay for procedure code 76770. You say that you disagree with the Plan's denial. 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 includes evidence that the items/services at issue were 
reimbursed by the Plan on June 30, 2023. Comparison of the two claims 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 76770 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76770 for date of service June 12, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of the denied 
SNF admission. The Plan denied your request. The Plan says SNF care is not practical or reasonable.   
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 that you are unable to make material gains within a predictable timeline.  
 
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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on June 13, 2023, 
to June 22, 2023. 
 
You asked the Plan to pay for the paramedic intercept services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Medicare coverage criteria was not satisfied. The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services provided on June 13, 2023, to June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 is digressing instead of getting better 
and they have not had any progress. You would like them to be transferred to another facility. The Plan denied 
your request. The Plan says the inpatient rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by the physical therapy note from October 10, 2023, and SLP note from October 11, 2023).  This 
enrollees condition is in fact complex and fragile, and there is every reason to expect that they will participate 
in and benefit from IRF level services. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), sphere single (V2100), and tint 
photochromatic lens (V2744), provided on January 31, 2023. 
 
You asked the Plan to pay for the frames, sphere single, and tint photochromatic lens. You say that the items 
should be covered. The Plan denied your request. The Plan says these items were not obtained through the 
Plan's preferred provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $200 single-purchase annual allowance for eyewear through the 
Plan's Vision provider.. 
 
We looked at the file and the Plan's rules. These items were not obtained through the Plan's preferred provider. 
Based on this information, we decided that the Plan's rules for coverage of the frames, sphere single, and tint 
photochromatic lens have not been met. Therefore, we decided that the Plan does not have to pay for the frames 
(V2020), sphere single (V2100), and tint photochromatic lens (V2744), provided on January 31, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on February 23, 
2023. 
 
You asked the Plan to pay for the PT services. You say that these services were medically necessary and were 
authorized. The Plan denied your request. The Plan says these services were rendered in an inpatient setting, so 
no payment can be made. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made if therapy services are 
provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or 
speech-language pathologist in private practice. 
 
In this case, the physical therapist is billing under the physician fee schedule. The PT services provided were 
rendered to a patient who was in an inpatient stay in a hospital on the date of service.  As a result, no separate 
payment can be made to the physical therapist. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PT services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy (PT) services provided on February 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on February 25, 
2023. 
 
You asked the Plan to pay for the PT services. You say that these services were medically necessary and were 
authorized. The Plan denied your request. The Plan says these services were rendered in an inpatient setting, so 
no payment can be made. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made if therapy services are 
provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or 
speech-language pathologist in private practice. 
 
In this case, the physical therapist is billing under the physician fee schedule. The PT services provided were 
rendered to a patient who was in an inpatient stay in a hospital on the date of service.  As a result, no separate 
payment can be made to the physical therapist. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PT services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy (PT) services provided on February 25, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a delay in treatment could jeopardize the enrollee's 
ability to return home at a safe functional level. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. Per Medicare Benefit Policy Manual, the medical record 
overall significantly complies with the various documentation requirements for IRF admission (e.g., as best 
summarized by physical and occupational therapy notes from October 10, 2023).  This enrollees condition is 
in fact complex and fragile, and there is every reason to expect that they will participate in and benefit from 
IRF services. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.