Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
December 1, 2022, through December 31, 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 psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on September 22, 2022 with 
Schizoaffective Disorder Bipolar Type. Based upon the review of the records provided, it was not expected that 
this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing 
any dangerousness to self or others, auditory or visual hallucinations, and was without aggressive behaviors 
while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or abnormal 
behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. This 
enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was 
not a danger to himself or others and did not have any delusions, or auditory and visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or were for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a 
physician. Based upon the review of the records provided, this enrollee does not meet the criteria for coverage 
of the acute inpatient mental health treatment provided beyond the date in question of December 1, 2022 
forward and could have been treated in a lesser restrictive 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from December 1, 2022, through 
December 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90834) provided on November 8, 2022, 
through November 23, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says the service was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Licensed Marriage & Family Therapists frequently attempt to enroll in 
Medicare but are not eligible to do so; no statute permits them to bill Medicare.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90834) provided on 
November 8, 2022, through November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital care provided by an 
in-network provider from January 2, 2023, to January 13, 2023. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital care. You say that you do not agree with 
the cost sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $800 deductible, and that you must pay a 10% coinsurance of the 
approved amount and the annual deductible applies, for in and out-of-network inpatient hospital care.   
 
 
 
 
 
 You have been asked to pay up to a 10% coinsurance for the inpatient hospital care. The item or service you 
asked the Plan to waive the cost sharing for falls within the inpatient hospital care benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies 
to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the 
inpatient hospital care was provided from January 2, 2023, to January 13, 2023. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the inpatient hospital care provided by an in-network provider 
from January 2, 2023, to January 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service October 25, 
2022, to November 1, 2022. You asked the Plan to pay for the billed services. You say that you initially submitted the claim in the wrong 
format. The Plan denied your request. The Plan says the NOA was not received timely.  
 
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 September 21, 2022. The NOA was not received by the Plan until January 
30, 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 care billed for 
dates of service October 25, 2022, to November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. The enrollee's pain appears 
to be multifactorial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows spinal stenosis. The cause of 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary because 
pulmonary therapy and physical therapy are offered there. The Plan denied your request. The Plan says 
admission to an IRF is not medically necessary.  
 
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 complexity of the enrollees 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 enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) provided on 
March 22, 2023. 
 
You asked the Plan to pay for the medication assisted treatment. You say that the service should be covered. 
The Plan denied your request. The Plan says the provider is not listed in the CMS data for OTP providers. 
 
The Plan must follow Medicare rules. Medicare rules say that An Opioid Treatment Program (OTP) must be 
enrolled under section 1866(j) of the Act; have in effect a certification by the Substance Abuse and Mental 
Health Services Administration (SAMHSA) for such a program; be accredited by an accrediting body approved 
by SAMHSA; and meets such additional conditions as the Secretary may find necessary to ensure the health 
and safety of individuals being furnished services under such program and the effective and efficient furnishing 
of such services.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medication assisted treatment have not been met. Specifically, that the provider is not listed in 
the CMS data for OTP providers. Therefore, we decided that the Plan does not have to pay for the medication 
assisted treatment (G2067) provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the requested setting is not on a home BiPAP. The 
Plan denied your request. The Plan says a BiPAP will meet the enrollee's needs.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has a diagnosis of chronic respiratory failure due to obesity hypoventilation syndrome. The records report no obstructive airway disease was seen on pulmonary function testing. The home ventilator 
is being requested for use in average volume assured pressure support (AVAPS) mode which is a modality that 
could be provided by a BiPAP device with AVAPS and a back-up rate. The provided records in this case do not 
provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a 
BiPAP device with AVAPS and a back-up rate. Therefore, the request 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 2, 2021, to June 
29, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the RAP was not received 
timely per Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that HHAs that do not submit a RAP within 5 days of the 
start of a period of care will have a non-timely penalty. 
 We looked at the file and Medicare rules. In this case, the file shows that a RAP was not submitted until August 
30, 2021, for the May 2, 2021, to June 29, 2021, dates of service. As such, the denial was correct. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from May 2, 
2021, to June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
August 11, 2023. 
 You asked the Plan to pre-approve SNF care after August 11, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
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 after August 11, 2023. 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 after August 11, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after August 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 X9). 
 You asked the Plan to pre-approve home health services. You say that this 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 clinical 
documentation does not specify any acute clinical status changes, changes in medications or plan of care 
thus the records do not show that skilled nursing services are required in the home setting 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 home health skilled nursing (G0299 X9).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937, and 99152 provided on February 8, 
2023. 
 
You asked the Plan to pay for procedure codes 76937, and 99152. You say that these codes were medically 
necessary. The Plan denied your request. The Plan says the codes billed are 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. 
 
We find that CPT codes76937, & 99152 are not supported in the medical record. Specifically, code 76937 is 
included in the cardiac catheterization procedure and is not separately payable. Records do not support the use 
of a trained independent observer for the sedation services. Code 99152 is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 76937, and 99152 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 76937, and 99152 provided 
on February 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on June 20, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 outpatient services were not supported in the medical record. Specifically, these services were performed on the same day as inpatient-only procedure C9606. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient services provided on June 20, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this procedure has not been found to be better or safer than 
standard treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 prostate artery embolization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a prostate volume of 87 cubic centimeters and post void volume 
of 287 milliliters which requires self-catheterization and resultant urinary tract infections. The request for 
prostate artery embolization as opposed to transurethral resection of the prostate (TURP) is reasonable and the 
interventional radiologist requesting the procedure has provided abundant references in support of the 
procedure and has shown the requested procedure is state of the art for interventional radiologists. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have been met. Therefore, we decided that the Plan 
has to pre-approve prostate artery embolization.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the primary 
payer needs to review the services for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services provided until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the radiology services provided on February 8, 2022.