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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 25, 2022, 
through November 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee presented to the 
emergency department with gradual worsening generalized weakness. The Plan denied your request. The Plan 
says that the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 the enrollee had an alcohol use disorder and presented to the emergency department with 
gradually worsening generalized weakness. The enrollee was found to have tachycardia and suicidal ideation. 
The workup and monitoring revealed they were in a state of alcohol withdrawal with a withdrawal assessment 
score of 24 at the time of admission. The enrollee was started on thiamine, folic acid, intravenous fluids, and 
benzodiazepines. The enrollee improved with treatment and was cleared of suicide precautions. Therefore, the 
enrollee was expected to require hospital treatment for detox that would have been expected to last at least 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 the acute inpatient hospital care provided from November 25, 2022, through November 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 26, 2022, 
through December 25, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid. 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.  
 
The Plan has not received the NOA claim and the submission of a NOA is beyond the required time limit. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
November 26, 2022, through December 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 15, 2022, 
through October 13, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid. 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.  
 
Review of the file shows that the NOA must be submitted within five (5) days of the start of care date for home 
health services. NOAs which are received more than 30 days start of care date result in no payment being made 
for the episode of care. The home health series of care was not submitted until December 28, 2022, which has a 
start of care/admission date of August 16, 2022. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from September 15, 2022, through October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis (L1902-LT) provided on November 18, 
2022. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. Review of the file shows that 
L1902-LT was not billed with a KX modifier. Claim lines billed with codes without a KX, GA or GZ modifier 
will be rejected as missing information. Therefore, we decided that the Plan does not have to pay for the ankle 
orthosis (L1902-LT) provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a peripheral nerve block rendered on March 1, 2023. 
 
You asked the Plan to pay for the block. You say that this should be paid for. The Plan denied your request. 
The Plan says that this was not billed with an appropriate diagnosis code. 
 The Plan must follow Medicare rules. Medicare rules say that services are covered if they are 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 pay for the block. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that one of the coverage criteria for these services is "when selective peripheral nerve blockade is used 
diagnostically in those cases in which the clinical picture is unclear, but this is only for diagnostic purposes and 
not long term treatment." This injection was both diagnostic and therapeutic for a patient with presumptive 
phantom limb pain. The procedure was medically reasonable and 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 block have been met. Therefore, we decided that the Plan has to pay for a 
peripheral nerve block rendered on March 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 11, 2023, 
through February 9, 2023. 
 You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 11, 2023. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from January 
11, 2023, through February 9, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services (G0299 and Q5001) provided from August 
23, 2021, through September 17, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that this charge is included in the contracted and/or case rate and includes any 
concurrency reductions that may apply. The Plan states that no additional payment will be made for this 
service. 
 
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 Plan stated there was no OASIS assessment which is why recoupment was 
requested; however, the provider submitted the assessment. Therefore, we find that the denial rationale based 
on that is not appropriate. Therefore, we decided that the Plan has to pay for the home health services (G0299 
and Q5001) provided from August 23, 2021, through September 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0110). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips for dialysis treatment. It is a life-or-death requirement for your medical condition. The Plan 
denied your request. The Plan says you have exhausted the maximum benefit of 50 one-way trips per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve a home health aide. You say that an aide is being requested to help you after 
your surgery. The Plan denied your request. The Plan says you do not meet the criteria set forth by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home health aide have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home 
health aide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs complex wound care. 
The Plan denied your request. The Plan says the LTACH services are not medically necessary, and the 
enrollee's needs can be met at lower level of care such as a skilled nursing facility or at home with home health 
services or outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided related to 
temporomandibular joint dysfunction (TMD) on December 22, 2022.  
 
You asked the Plan to pay for the PT services. You say that this therapy was ordered to treat the enrollee's 
TMD. This care was necessary.  The Plan denied your request. The Plan says this is not a service that can be 
covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the PT services. Our reviewer says that the 
PT provided on this date of service is not shown to be reasonable and necessary.  Our physician reviewer found 
the provided records in this case do not document the PT was primarily focused on a medical condition rather 
than being services to treat structures supporting the teeth. The records also do not document the PT met 
Medicare criteria for medically reasonable and necessary for the enrollee. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the physical therapy (PT) services provided related to temporomandibular joint dysfunction 
(TMD) on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes (99239) and subsequent hospital care (99223) provided on February 14, 2023. 
 You asked the Plan to pay for the service. You say that the provider should be paid regardless of other claims. 
The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the file shows that the 
enrollee was in outpatient observation; therefore, it would be inappropriate to report CPT 99239 and CPT 
99223-AI in inpatient place of service 21. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management; more than 30 minutes (99239) and subsequent hospital care (99223) 
provided on February 14, 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  the IRF care is medically necessary. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility, home care or outpatient therapy services. 
 
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 was admitted for knee replacement surgery and was discharged home. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra lightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee cannot go far distances. The Plan 
denied your request. The Plan says there is no documentation of a face-to-face evaluation. 
 
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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is noted to be experiencing mobility issues, but at the same time can ambulate 
with a rollator. There is no formal wheelchair evaluation as well as no information regarding the enrollee's 
level of mobility and ability to perform daily activities. There is no documentation indicating why the enrollee 
cannot use a lightweight or standard wheelchair and requires an ultralight weight manual wheelchair. There is a 
lack of documentation indicating that the enrollee can use the wheelchair and that his home is accessible for it. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ultra lightweight wheelchair (K0005).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a positron emission 
tomography (PET) scan. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are available in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a positron emission tomography (PET) scan.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies and materials (99070) provided on January 4, 
2022. 
 
You asked the Plan to pay for the supplies and materials. You say that you fell and were taken to the 
emergency room for treatment. The Plan denied your request. The Plan says this claim was untimely, and the 
submission did not meet the exception criteria guidelines. 
 
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 supplies and materials was not filed until January 12, 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 supplies and materials (99070) provided on January 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 11, 2022, to 
May 10, 2022, as billed. 
 
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 services are not covered as 
billed. 
 
The Plan follows Medicare rules. The rules say while HH PPS payment is now made for each 30-day period, 
the home health PPS permits continuous 60-day recertifications for patients who continue to be eligible for the 
home health benefit. 
 
We reviewed the file and the Medicare rules. We find that the file shows the 60-day certification period was 
billed as two separate 30-day payment periods. The claim at issue represents the second 30-day payment period 
(April 11, 2022, to May 10, 2022). Per the requirements, the Recertification OASIS should be performed 
within the last five days of each 60-day recertification period. The Recertification OASIS for this billed episode 
of care should have been performed between the dates of March 7, 2022, to March 11, 2022; as the next 60-day 
episode began on March 12, 2022. The Recertification OASIS provided in this case was dated May 10, 2022. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from April 11, 
2022, to May 10, 2022, as billed.