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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of hypertension, deep vein thrombosis, gastric bypass surgery and duodenal carcinoma who 
presented to the acute hospital on 10/10/2020 with abdominal pain related to a large bowel obstruction. She 
was treated in the hospital with an exploratory laparotomy, small bowel resection, colostomy creation and 
appendectomy. She has a percutaneous feeding tube. She is weak and deconditioned and is working with 
physical and occupational therapy. She is walking 12 feet with hand holding or a rolling walker with moderate 
to maximum assistance and is moderate to maximum assist for transfers and activities of daily living. She is 
reported to be medically stable for discharge. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup provided on February 5, 2020. 
 
You asked the Plan to pay for core buildup. You say that the dental office informed you all services were 
approved. You say that you were informed you had $1,000 available and you cannot afford to pay. The Plan 
denied your request. The Plan says your annual maximum of $1,000 is exhausted. 
 
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, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward your dental benefits received on January 8, 2020 and February 5, 2020, 
which exhausted your benefit. After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay for the core buildup provided on 
February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on 
January 22, 2020 by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that these services were 
rendered due to medical necessity. The Plan denied your request. The Plan says these services were rendered 
by a non-contracted provider. The Plan also says that the care was not approved in compliance with the 
Medicare Health Plan's authorization procedures. 
 
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 has network providers 
available who can provide 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 ambulance service and ground mileage 
provided on January 22, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
October 21, 2020 and forward. 
 
You asked the Plan to pre-approve continuation of inpatient mental health care from October 21, 2020 and 
forward. You say that the requested continuation of inpatient mental health care from October 21, 2020 and 
forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of 
inpatient mental health care from October 21, 2020 and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental health 
care from October 21, 2020 and forward. Our reviewer says that the requested continuation of inpatient mental 
health care from October 21, 2020 and forward is not medically necessary. Our physician reviewer found based 
upon review of the records provided, this enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of October 21, 2020 and forward as treatment can be provided in a lesser 
restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations and was not showing any behaviors. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health care from October 21, 2020 and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient 
mental health care from October 21, 2020 and forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) rendered on February 15, 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an AFO is covered when specific criteria are 
met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee presented on October 7, 2019 
with mild swelling in the left lower leg. The documentation in the case file does not support that the requested 
ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the 
criteria established by the LCD. The documentation does not support that the enrollee in this case required 
ankle/foot stabilization for medical reasons, and that she has the potential to benefit functionally. 
 
We looked at this physician's review, the file, and Medicare rules. 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 ankle-foot orthosis (AFO) rendered on February 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study provided on December 27, 2019 by an 
OON provider. 
 
You asked the Plan to pay for the extremity study. You say that precertification is not required for radiology 
imaging under the enrollee's plan. The Plan denied your request. The Plan says the service was rendered by a 
non-contracted provider. The Plan also says that 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 requested provider in this case is not a network provider with the Plan. 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 extremity study provided on December 27, 
2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat lift mechanism, electric, any type (CPT Code 
E0627). 
 
You asked the Plan to pre-approve the DME. You say that your provider asked for you to have a lift recliner 
for a seat (to make easier to get up from sitting to standing position) because you have difficulty getting up. 
The Plan denied your request. The Plan says Medicare only covers  an item when it is used for a medical need 
and not for a comfort, convenience,  or self-help need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Per Medicare rules the electric seat lift should be serving to improve function of an individual with severe 
arthritis of the hip and or muscular dystrophy. A care plan should be included to show the how the DME would 
enhance function not comfort. 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 seat lift mechanism, electric, 
any type (CPT Code E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested semi-electric hospital bed is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 a semi-electric hospital bed. Our 
reviewer says that the documentation does not support that the requested semi-electric hospital bed is medically 
reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of other cervical disc 
degeneration unspecified cervical region. The enrollee has chronic low back and neck pain, myalgia and 
chronic pain. The enrollee is noted to have GERD and it is noted that the enrollee's symptoms would improve 
with maintaining elevation of the head of the bed. The documentation does not clearly reveal that enrollee's 
condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed 
in other ways is not feasible. The documentation does not support a need for an immediate or frequent change 
in body position or special attachments that cannot be fixed on an ordinary bed. The head of the bed does not 
need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary 
disease, or problems with aspiration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the tympanometry, impedance testing 
(92567) and the comprehensive audiometry threshold evaluation and speech recognition test (92557) provided 
on July 2, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $25 
copayment for an annual hearing exam.  
 
You have been asked to pay a $25 copayment for the annual hearing exam provided. 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 the tympanometry, impedance testing (92567) and the comprehensive audiometry 
threshold evaluation and speech recognition test (92557) provided on July 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on December 16, 2019. 
 
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these codes 
are supported in the record. The Plan denied your request. The Plan says these procedures are not documented. 
 
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 95907 is nerve conduction studies; 1-2 studies, and the 
definition of 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, 
done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code 
for primary procedure). 
 
We find that CPT codes 95907 and 95885 are not supported in the medical record. Specifically, no nerve 
conduction studies are documented in the medical records. Based on this information, we decided that 
Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. 
Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary because 
sacroiliac joint injections have provided significant but short-lived relief. The Plan denied your request. The 
Plan says this is experimental. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found non-thermal radiofrequency modalities for facet joint denervation including chemical 
denervation do not meet Medicare criteria for medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits (97112, 
97012, 97113, 97110). 
 
You asked the Plan to pre-approve the additional PT visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has been trained in an independent exercise 
program. Her symptoms are persistent and getting worse and she may need re-evaluation of her condition from 
her physician. The specialized skill, knowledge and judgment of a qualified therapist is not required to 
establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
 
 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy (PT) visits (97112, 97012, 97113, 97110).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 additional PT visits. 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 Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this 
condition and it does not appear that the enrollee requires the ongoing unique skills of a professional therapist 
to safely and effectively provide treatment, or that the services can be safely and effectively performed only by 
a therapist, or under the supervision of a therapist. The enrollee has been educated in a home exercise program 
and ensure safety. The enrollee's functional deficits that remain are not so significant that she cannot address 
them with continued participation of a home exercise program. The specialized skill, knowledge and judgment 
of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
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 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, only  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair repair to a secondary device. 
 
You asked the Plan to pre-approve a wheelchair repair to a secondary device. You say that you need repairs on 
this wheelchair. The Plan denied your request. The Plan says repairs made to a secondary or back-up 
wheelchair which is owned by the patient for use in the home, school, or for other activities, will not be 
approved. 
 
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 a wheelchair repair to a secondary device have not been met. The 
records were given to show that this is not your primary wheelchair. Repairs to a secondary or back up 
wheelchair are not covered. Therefore, we decided that the Plan does not have to pre-approve a wheelchair 
repair to a secondary device.