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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the IRF admission 
criteria. The Plan denied your request. The Plan says the Medicare coverage criteria for an IRF admission has 
not been met. 
 
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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that 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 acute IRF admission and services.
Appeal type: Surgery
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) provided on March 
2, 2020. 
 
You asked the Plan to pay for the services. You say that it takes a half hour to an hour to set up the Heart Lung 
Machine. The Plan denied your request. The Plan says Medicare does not pay any provider or supplier for 
items and non-physician services furnished to the beneficiary while an inpatient in hospital. 
 
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 for items and non-physician 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. Any and all codes on this claim are denied, and in addition, previous payments to 
these providers for this member are subject to recoupment. 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) provided on March 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 the therapy requested can be delivered at a lower level of care under 
Medicare Part B services as needed. 
 
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 the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
26, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges 
because you never had to pay in the past. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for laboratory services.  
 
You have been asked to pay a $35 copayment for laboratory services. Laboratory services fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for laboratory services provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4525). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4525).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial reconstructive surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve facial reconstructive surgery. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 
a network provider. 
 
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 
facial reconstructive surgery to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the enrollee would benefit from an inpatient 
rehab. The Plan denied your request. The Plan says the request for IRF services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization administration (includes percutaneous, 
intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (CPT 
Code 90471) and tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to 
individuals 7 years or older, for intramuscular use (CPT Code 90715) provided on February 19, 2019. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says your Part B covers influenza vaccine, pneumococcal 
vaccine and Hepatitis B vaccine for intermediate and high risk beneficiaries. The Plan states your Medicare 
Part B plan covers vaccines that are necessary to treat an injury or illness. The Plan states in order to have this 
service reimbursed you must submit a copy of your paid receipt along with the attached completed Part D 
Claim reimbursement form. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization administration (includes 
percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination 
vaccine/toxoid) (CPT Code 90471) and tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when 
administered to individuals 7 years or older, for intramuscular use (CPT Code 90715) provided on February 19, 
2019.  
 
Benefits for the services 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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment only in a SNF.  The enrollee does 
not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
 
 
safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does 
not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a 
SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cerebral Perfusion Analysis (0042T) provided March 13, 
2020. 
 
You asked the Plan to pay for Cerebral Perfusion Analysis. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 0042T is not supported in the medical record. Specifically, CPT code 0042T is non-
covered. Based on this information, we decided that Medicare rules for coverage of Cerebral Perfusion 
Analysis have not been met. Therefore, we decided that the Plan does not have to pay for Cerebral Perfusion 
Analysis (0042T) provided March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 13, 2020. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the enrollee was not a new 
patient for this visit. 
 
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 99205 is not supported in the medical record. Specifically, the enrollee was provided 
services by this practice within 3 years of the visit in question. This means that the enrollee should not be 
considered a new patient for this visit. Based on this information, we decided that Medicare rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit provided on May 13, 2020.
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 is stable and suitable for 
transfer to a LTAC. You also say that the enrollee requires daily physician management with close medical 
monitoring, and cannot be adequately cared for in his current condition at a skilled nursing facility. The Plan 
denied your request. The Plan says the LTACH admission is not medically necessary. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Our physician reviewer also found that short-term 
additional acute care services are needed and can be administered at the current facility safely. Transfer may be 
considered when more stable or when a more formal prediction of outcome and expectations with care is noted. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external radiation dosimetry. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says research 
has not shown the requested treatment would improve outcomes in the enrollee. 
 
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 requested services. Our physician 
reviewer found that Radium-223 (Ra-223) is a radiopharmaceutical that emits alpha particles, radioactive 
particles that have a low penetrance and therefore deposit their dose close to their source. The radioactive Ra-
223 preferentially targets bone metastases. Because of the low penetrance through tissue, it has a low bone 
marrow toxicity profile. The most recent NCCN guidelines consider Radium-223 a category 1 recommendation 
as a 1st or 2nd line therapy for metastatic prostate cancer without visceral metastases. It is not included in the 
guidelines for those with visceral metastases. For this enrollee, Ra-223 would be considered medically 
necessary and standard of care in the setting of symptomatic bone-only metastatic disease. In this case, with 
visceral metastases and no records documenting bone pain, Ra223 would not be furnished in accordance with 
accepted standards of care. Therefore, the requested services are not considered medically reasonable or 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve external radiation dosimetry.
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 the therapy needs are not inherently complex and do not require an 
interdisciplinary approach, 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 hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for trauma evaluation after being 
struck by a care. You had surgical repair of right leg fractures. Your medical problems are stable. There are no 
identified problems that need inpatient medical management. 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. The medical record supports a need for physical and 
occupational therapy but it does not support a need for 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429) provided on May 5, 2020. 
 
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was billed without necessary modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that in the case where the 
beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, 
providers report the A0428 (BLS) HCPCS code with modifier QL and either QM or QN. 
 
We find that CPT code A0429-QL is not supported in the medical record. Specifically, the beneficiary was 
pronounced dead after the ambulance was called, but this was not billed with the QM or QN modifier, and was 
reported with A0429 rather than A0428. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services (A0429) provided on May 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira Pen for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Humira Pen for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.