Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesn't support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. Our physician reviewer found that 
your condition does not meet Medicare criteria for IRF 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your therapy needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF 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: Favorable

We decided that the Plan has to pay for needle electromyography; 2 extremities with or without related 
paraspinal areas (CPT Code 95861) provided on August 2, 2019. 
 
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 the services are not supported by the records. 
 
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 services. Our physician reviewer found 
the review of the operative not indicates that the needle electromyography; 2 extremities with or without 
related paraspinal areas (CPT Code 95861) provided on August 2, 2019, was performed. The review has 
determined that the services were supported in the medical records. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
needle electromyography; 2 extremities with or without related paraspinal areas (CPT Code 95861) provided 
on August 2, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the subsequent hospital care. We decided that the Plan does not have to 
pay for gastrointestinal tube and septal strap placement.  
 
You asked the Plan to pay for the subsequent hospital care, gastrointestinal tube and septal strap placement. 
You say that you would like reconsideration based on the records submitted. The Plan says that it is not 
appropriate for identical specialties to exchange consults and the documentation does not support CPT codes 
44500 and 30999. 
 
We decided that the Plan has to pay for the subsequent hospital care.  
 
The Plan follows Medicare rules. Medicare rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the subsequent hospital care have been met.  Specifically, this provider is not the same 
specialty of the other provider who billed for this service. Therefore, we decided that the Plan has to pay for the 
subsequent hospital care.  
 
We also decided that the Plan does not have to pay for gastrointestinal tube and septal strap placement. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures 
should be reported with the CPT code that describes the services performed. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for gastrointestinal tube and septal strap placement. Our 
reviewer says that CPT code 44500 does not meet criteria for billing or reimbursement consideration. The 
medical records provided do not include documentation of an Introduction of long gastrointestinal tube (eg, 
Miller-Abbott) (separate procedure) being performed on March 30, 2020, therefore this service cannot be 
verified. Our physician reviewer found CPT code 30999 does not meet criteria for billing or reimbursement 
consideration.  CPT 30999 is included in the DRG package for the member's hospitalization and is not 
separately reimbursable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastrointestinal tube and septal strap placement have not been met. Therefore, 
we decided that the Plan does not have to pay for gastrointestinal tube and septal strap placement. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from December 26, 
2019, to December 27, 2019. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee received medically necessary care 
and this should be covered. The Plan denied your request. The Plan says the enrollee was not unstable for 
transfer and no request for authorization for out of network care was made. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
documentation supports that the services provided were unauthorized post-stabilization care. Our physician 
reviewer found the enrollee was hemodynamically and neurologically stable and appropriate for ambulance 
transport with monitoring to a network facility for observation/admission level of care services after the 
emergency room evaluation on 12/26/19. There was no documentation provided necessitating the post-
stabilization care services at the non-Plan facility. The treating physician did not document (in the physician 
notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient hospital care provided from December 26, 2019, to December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that you have a relationship with the out of 
network provider. The Plan denied your request. The Plan says they have in-network providers who can 
provide the requested services. 
 
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 
the medical services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on April 14, 2020. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the item rendered was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered for certain 
indications. 
 
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 knee orthosis. Our reviewer says that the 
documentation does not support that the knee orthosis provided was medically reasonable or necessary. Our 
physician reviewer found the office visit notes show that the enrollee has tenderness, swelling, abnormal range 
of motion on right lower extremity exam. The left lower extremity has stiffness. The L1833 knee orthosis is not 
medically necessary as the enrollee has not had recent injury to or a surgical procedure on the knee(s). The 
enrollee is noted to be ambulatory. The documentation does not reveal instability on an objective physical 
exam of the right knee. Therefore, the enrollee did not meet criteria for the item rendered. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee orthosis provided on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a contoured seat with a cup holder (K0108) for a 
powerchair. 
 
You asked the Plan to pre-approve the contoured seat with a cup holder. You say that the seat and cup holder 
are medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a contoured seat with a cup holder (K0108) for a 
powerchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 18 and 31, and core build up 
(D2950) for tooth # 18. 
 
You asked the Plan to pre-approve the dental services. You say that that the crowns on teeth # 18 and 31 broke 
off. You also say that you need them replaced. The Plan denied your request. The Plan says crowns and core 
build up are covered once per tooth every 5 years. The Plan says the frequency limit for these services has been 
reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crowns and core build up are 
covered services, the frequency limits of once per tooth, every 5 years has been reached. The record shows you 
received a crown and core build up for tooth # 18 on October 30, 2019 and a crown for tooth # 31 on 
November 6, 2019. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth 
# 18 and 31, and core build up (D2950) for tooth # 18.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way transportation 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation in excess of the allowed 24. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you would like 
reconsideration because this service is necessary for you to be able to get to your appointments. The Plan 
denied your request. The Plan says the additional trips are non-covered. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that after your 24th trip, you will have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve routine transportation in 
excess of the allowed 24.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation 
that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) and red blood 
cells, washed, each unit (CPT Code P9022) provided on March 10, 2020. 
 
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 enrollee received the services in the facility during inpatient hospitalization, and 
payment for this service would be included in the part-A DRG payment to the facility. The Plan states the 
payment for this service is the responsibility of the facility to any vendor. 
 
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 services have not been met. Medicare does not pay any 
provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in 
hospital, and this takes precedence over the claim system denial. The facility must furnish all necessary 
covered services to the beneficiary either directly or under arrangements made between the facility and outside 
vendors. The enrollee received the services in the facility during inpatient hospitalization, and payment for this 
service would be included in the part-A DRG payment to the facility. Payment for this service is the 
responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for 
assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure 
monitoring); each hour (CPT Code 99190) and red blood cells, washed, each unit (CPT Code P9022) provided 
on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complex endovascular aneurysm repair (34848). 
 
You asked the Plan to pre-approve a complex endovascular aneurysm repair. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a complex endovascular aneurysm repair as part of a clinical 
trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that 
the Plan does not have to pre-approve a complex endovascular aneurysm repair (34848).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto 15 MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this drug is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto 15 MG tablet.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you appear to need custodial care rather than skilled nursing facility 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.