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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.
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. Our physician reviewer found 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 had a prolonged admission for pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for bilateral below the knee amputation for severe peripheral vascular disease. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 IRF. 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: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysdue to non-weight-bearing status, the enrollee is unable to respond to daily skilled therapy with material gains within a predictable timeline.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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. You do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case until the non-weight bearing restriction is lifted for the left upper extremity.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care rendered on August 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99220 is not covered. 
 
The Plan must follow Medicare rules. The rules say that A/B MACs (B) pay a physician for only one hospital 
visit per day for the same patient 
 
We looked at the file and Medicare rules. The file shows that procedure code 99220 was previously billed and 
paid by the Plan by the same provider for the same date of service. 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 initial observation care rendered on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Hereditary Cancer Panel (81201, 81162, 81203) provided 
February 1, 2020. 
 
You asked the Plan to pay for the Hereditary Cancer Panel. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this was not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and 
are not covered.  
 
We looked at the file and Medicare rules. The test was ordered to detect an undiagnosed disease or disease 
predisposition. This is not a covered service. Based on this information, we decided that Medicare rules for 
coverage of the Hereditary Cancer Panel have not been met. Therefore, we decided that the Plan does not have 
to pay for a Hereditary Cancer Panel (81201, 81162, 81203) provided February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy rendered from January 2, 2020 
to March 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the claims for these services were not billed with 
an appropriate primary diagnosis code. 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 medical 
nutrition therapy rendered from January 2, 2020 to March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell out of your chair and the medics 
assisted you to get back up. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services and self-administered drugs 
provided on August 18, 2020. 
 
You asked the Plan to pay for the outpatient hospital services and self-administered drugs. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed without the G0 condition 
code which caused the services to deny.  
 
The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-
administered drugs provided here are not among the types which are covered by Medicare Part B. 
 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services and self-
administered drugs provided on August 18, 2020.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four monitoring (95937) and sterile needles 
(A4215) provided on May 23, 2020. 
 
You asked the Plan to pay for the train of four monitoring and needles. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says code A4215 is 
excluded by Medicare and 95937 is not supported by the medical records submitted. 
 
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 CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT codes 95937 and A4215 are not supported in the medical record. Specifically, train of four 
monitoring is considered integral to the primary service and not separately payable. Additionally, CPT code 
A4215 is statutorily excluded from payment. Based on this information, we decided that Medicare rules for 
coverage of the train of four monitoring and needles have not been met. Therefore, we decided that the Plan 
does not have to pay for the train of four monitoring (95937) and sterile needles (A4215) provided on May 23, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81599) provided July 24, 2020. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services 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 CPT code 81599 is not supported in the medical record. Specifically, there was no explanation of 
the unlisted CPT code with the claim. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(81599) provided July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 25, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all 
cardiovascular risk assessment panels. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Medicare denies coverage for all cardiovascular risk 
assessment panels except for the basic lipid panel. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on May 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95955, 95941, 95938, 95908) 
provided on April 25, 2019. 
 
You asked the Plan to pay for neuromonitoring services. You say that this claim was filed timely. The Plan 
denied your request. The Plan says this was filed more than a year after the services. 
 
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 neuromonitoring services was not filed until August 3, 2020. 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 neuromonitoring services (95955, 95941, 95938, 95908) 
provided on April 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops. 
 
You asked the Plan to pre-approve Rocklatan. You say that this service is medically necessary for the enrollee. 
The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your 
medical benefit. 
 
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 Rocklatan drops.  
 
Benefits for Rocklatan 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291) provided December 28, 2019 to 
December 29, 2019. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this item is not separately payable. 
 
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 code 99291 is not supported in the medical record. Specifically, a required modifier was not 
included to denote that this was a distinct and separate service from other physician services already paid. 
Based on this information, we decided that Medicare rules for coverage of the physician services have not been 
met. Therefore, we decided that the Plan does not have to pay for physician services (99291) provided 
December 28, 2019 to December 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E2365 and K0856). 
 
You asked the Plan to pre-approve the wheelchair. You say that your current wheelchair is falling apart. The 
Plan denied your request. The Plan says you are able to get around in your apartment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal that you have a personal mobility deficit that impairs participation in MRADLs 
in the home. Your ambulation is currently helped by a walker. The documentation does not support that the 
power wheelchair will significantly improve MRADLs in the home. You do not have a mobility limitation due 
to a neurological condition, myopathy, or congenital skeletal deformity 
 
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 a power wheelchair (E2365 and K0856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses coded L1833, the addition to lower 
extremity orthoses coded L2397, and the lumbar-sacral orthosis coded L0650 provided on July 23, 2020. 
 
You asked the Plan to pay for the knee orthoses, the addition to lower extremity orthoses, and the lumbar-sacral 
orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the documentation is missing required information. 
 
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 codes L1833, L2397, and L0650 are not supported in the medical record. Specifically, the 
documentation does not contain sufficient documentation of the patient's medical condition to substantiate the 
necessity for the type and quantity of items ordered and for the frequency of use. The documentation does not 
support any evidence of an established relationship between the enrollee and the ordering physician. The 
documentation does not include sufficient documentation to corroborate the items rendered. Based on this 
information, we decided that Medicare rules for coverage of the knee orthoses, the addition to lower extremity 
orthoses, and the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have 
to pay for the knee orthoses coded L1833, the addition to lower extremity orthoses coded L2397, and the 
lumbar-sacral orthosis coded L0650 provided on July 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided April 29, 2020, through May 
5, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the services were 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 record showed that at the time of inpatient admission, the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two 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. Specifically, it was expected that 
the enrollees care would span two midnights at the time of the inpatient admission. This means the service was 
medically necessary. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care 
provided April 29, 2020, through May 5, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core build up (D2950), crown (D2740), and the 
upper partial denture (D5211). 
 
You asked the Plan to pre-approve the core build up, crown, and partial denture. You say that the services are 
necessary. The Plan denied your request. The Plan says core build up is not listed and therefore is not a covered 
service. The Plan says that the crown is not listed and therefore is not a covered service. The Plan says the 
partial denture is not listed and therefore is not a covered service either. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core build up (D2950), crown (D2740), and the upper partial denture (D5211).