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

 
We decided that the Plan does not have to pay for the home health services provided from November 22, 2022, 
to December 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the certification period submitted 
is correct. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from November 22, 2022, to 
December 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the 
LTACH level of care to manage their complex comorbidities. You also say admission to the LTACH could 
avoid any further readmission to the acute hospital setting. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from September 20, 2021, to 
September 21, 2021. 
 
You asked the Plan to pay for the medical services. You say that you believe the Plan allows 18 months to 
correct a claim. The Plan denied your request. The Plan says you did not timely file this claim. 
 
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 medical services was not filed until January 24, 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 medical services provided from September 20, 2021, to 
September 21, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, emergency transport and ground 
mileage provided on December 1, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport and ground 
mileage. You say that the services should be covered and are requesting payment for this claim. The Plan 
denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan denied payment for this service 
on the basis that it is a duplicate of another claim that was already paid. However, the other claim the Plan 
submitted is for a separate ambulance trip and was billed with the appropriate modifiers to distinguish it from 
the service at issue in this case. The Plan did not submit any other evidence of a duplicate claim. Based on this 
information, we decided that Medicare rules for coverage of the ambulance service, basic life support, 
emergency transport and ground mileage have been met. Therefore, we decided that the Plan has to pay for 
ambulance service, basic life support, emergency transport and ground mileage provided on December 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the berkeley shells (L3000 x2) provided on May 6, 2022. 
 
You asked the Plan to pay for the foot orthotics. You say that you got orthotics but before getting them, you 
asked the provider as well as the Plan, and were told that these items/services were covered, aside from the $70 
copay you were told you had to pay. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the berkeley shells (L3000 x2) provided 
on May 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapies provided on December 1, 2022, and 
December 7, 2022, by an OON provider.  
 
You asked the Plan to pay for outpatient therapies provided by an OON provider. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advanced. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient therapies provided on December 1, 
2022, and December 7, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99217 billed for date of service January 9, 2023. 
 
You asked the Plan to pay for code 99217. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 99217 is no longer valid. 
 
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 codes for reporting observation care services (9921799220) were deleted effective January 1, 
2023. Observation care services have been merged into the codes previously used to report only inpatient care 
services (9922199233, 9923899239).  You will need to rebill these services using one of these new codes. 
Therefore, we decided that the Plan does not have to pay for code 99217 billed for date of service January 9, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on October 10, 
2022. 
 
You asked the Plan to pay for the laboratory services. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
No medical records from the ordering physician were provided for review to determine medical necessity. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81479) provided on 
October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 21, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network outpatient physical and 
occupational therapy provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from 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 
a referral to an out-of-network outpatient physical and occupational therapy provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease 
Bundle (81479) provided on September 23, 2022 
 
You asked the Plan to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
the claim for this molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. The correct z-code for the covered Guardant Reveal Post-Surgery Minimal Residual Disease 
Bundle is Z00D6. The claim was billed with z-code Z00D5 for the non-covered Guardant Reveal testing. 
Based on this information, we decided that Medicare rules for coverage of the Guardant Reveal Post-Surgery 
Minimal Residual Disease Bundle have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle (81479) provided on September 23, 
2022
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric evaluation services provided on September 15, 
2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the OON psychiatric evaluation services. You say that the services were 
provided in the emergency room, and you were not aware that they would be unpaid.  The Plan denied your 
request. The Plan says they did not receive prior authorization for the OON services provided. 
 
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. Medicare rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the OON 
services at issue. The services in dispute were billed as telehealth services and not billed as having been 
performed in the emergency room. We found no exception that would require the Plan to pay for these OON 
services. In addition, there were no medical records provided. The Plan has shown that they made reasonable 
attempts to obtain medical records. Without this necessary information, we are unable to determine if Medicare 
rules for coverage of OON care have been met or if the services were in fact performed in an emergent 
situation. Therefore, we decided that the Plan does not have to pay for psychiatric evaluation services provided 
on September 15, 2022, by an out-of-network (OON) provider.
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 enrollee meets the criteria for admission to an 
IRF. You would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post cataract laser surgery provided on December 8, 2022, to 
January 25, 2023. 
 
You asked the Plan to pay for post cataract laser surgery. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says the primary explanation of benefits was not received and 
therefore denied. 
 
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 instructed 
that this claim should go to your primary insurance carrier with primary payment information sent to the Plan.. 
As the secondary insurer, the Plan cannot be held responsible for post cataract laser surgery until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for 
post cataract laser surgery provided on December 8, 2022, to January 25, 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 services are medically necessary for you to 
receive the proper level of therapy services before returning home. The Plan denied your request. The Plan says 
that you do not meet the criteria for admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on January 13, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on January 13, 
2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve assisted living facility (ALF) residency. 
 
You asked the Plan to pre-approve ALF residency. You say that the enrollee needs assistance with dressing, 
bathing, eating, and more. The Plan denied your request. The Plan says this service is excluded from Medicare 
coverage. 
 
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 ALF residency 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 assisted living 
facility (ALF) residency.