Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a SNF from an IRF care. 
 
You asked the Plan to pre-approve the services. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 documentation provided, 
you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have 
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program 
or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical 
matter, can be provided at a lower level of care. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a SNF from an IRF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 23, 2020 by an out 
of network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 medical services provided on January 23, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT), abdomen and pelvis (74176) 
provided June 23, 2020. 
 
You asked the Plan to pay for the CT scan. You say that you ask for review of the attached material and 
reprocess per the additional information provided. The Plan denied your request. The Plan says this procedure 
is inclusive to CPT code 74177 which was billed for the same date of service by another provider within the 
same group. This service cannot be billed separately. 
 
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 billing of code 74176 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day Based on Medicare billing guidelines, this claim cannot be paid as billed. To add, per CMS 
CCI procedure to procedure edits, CPT code 74176 is a column II procedure to the column I procedure, 74177. 
However, a modifier is allowed to indicate that these services are distinct.  Per the review of the submitted 
documentation, CPT code 74176 is supported as being distinct, however, a modifier indicating that it is a 
separate and distinct service was not appended. Therefore, we decided that the Plan does not have to pay for 
computed tomography (CT), abdomen and pelvis (74176) provided June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that your existing oxygen 
concentrator does not last long enough to meet your needs. The Plan denied your request. The Plan says the 
existing concentrator is less than 5 years old and there are no records showing it does not function correctly. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you already have a portable oxygen concentrator. This portable oxygen concentrator serves 
the same purpose as the requested portable oxygen concentrator. Therefore, we decided that the Plan does not 
have to pre-approve a new portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis heel height adjustment 
feature (L5990). 
 
You asked the Plan to pre-approve a lower extremity prosthesis heel height adjustment feature. You say that 
this is necessary for fall prevention. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that a user-adjustable heel height feature will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested item is not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of a lower extremity prosthesis heel height 
adjustment feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
lower extremity prosthesis heel height adjustment feature (L5990).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the enrollee's rides consists of primary care 
doctor's appointments, eye appointments, therapists and now he is in physical therapy. Please grant this appeal 
and reconsider adding more rides. The Plan denied your request. The Plan says this request exceeds the 
transportation benefit limit. 
 
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 one way trips 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 5 additional transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON consultation. You say that  The Plan denied your request. The Plan 
says you do not meet the guidelines for coverage of OON care. The Plan says that there are network doctors 
who can provide the care needed. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on November 25, 2019. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the genetic testing 
rendered on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is the best 
course of treatment due to the enrollee's complex medical needs, as well as to free up valuable resources at the 
short-term acute care hospital in view of the current COVID-19 pandemic. The Plan denied your request. The 
Plan says rules for LTACH care have not been met. 
 
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 is receiving acute hospital care and acute care services have not been 
denied. LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. The enrollee's chest X-ray was worsening as of October 18, 2020, and there are no clinical notes 
available for review since that date. The documentation is insufficient to demonstrate that the enrollee is stable 
for transfer to an LTACH at this time. 
 
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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses.You asked the Plan to pay foreyeglasses. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says therequested items can be provided by a network provider and that you are responsible for anything over $400.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 anything over $400 for eyewear.Review of the file shows that you are requesting quotes from different optical providers. An out of network optical provider quoted you $230 for the eyeglasses you need. You feel the plan should cover the $230 to be provided by an out-of-network provider so that you would not have to pay anything out of pocket. You have been asked to pay anything over $400 for eyeglasses. The eyeglasses fall within the vision services 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 pay foreyeglasses.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would be best cared for in 
the LTACH setting. The Plan denied your request. The Plan says there is no clinical advantage in going to 
LTACH over remaining in the current facility. 
 
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 patient is a 78-year-old male who was admitted to the current acute care hospital 
with failure to thrive, diagnosed with metabolic encephalopathy chronic anemia, chronic trach use, 
hyponatremia, protein calorie malnutrition, and hypokalemia. The course was complicated by cardiac arrest, 
acute respiratory failure, and anoxic brain injury requiring continued supportive care and mechanical 
ventilation. Long-term prognosis is stated as being poor. Only supportive care is planned at the current time. 
 
The patient appears to require only short-term acute care services at this time (less than 25 days) as only 
supportive care is planned. The patient does not require services at the LTACH that are not already available at 
the current facility. Therefore, this request for LTACH services will be considered not medically necessary at 
this time. Transfer to a lower level of care soon appears most appropriate. 
 
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 long-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenon-sterile gloves (A4927).You asked the Plan to pre-approvethe non-sterile gloves. You say that you would like reconsideration because you require these gloves to help clean the member and they have become hard to fine and more expensive.The Plan denied your request. The Plan says the non-sterile gloves do not meet the definition of covered DME as they cannot withstand repeated use, do not primarily serve a medical purpose and are useful in the absence of illness or injury.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-approvenon-sterile gloves (A4927).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve lumbar spinal fusion. The Plan denied your request. The Plan says that this 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 lumbar spinal fusion. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had residual low back and bilateral lower extremity pain with recent onset of 
episodic urinary incontinence, numbness of the groin and vagina, and occasional muscular issues with bowel 
movements. There is imaging evidence of multilevel moderate to severe lumbar neuroforaminal stenosis due to 
facet arthropathy, disc protrusions, and degenerative disc disease. There is reported radiographic evidence of 
thoracolumbar kyphosis and significant lumbar degenerative scoliosis with a Cobb angle of 34 degrees. She has 
failed long-term non-operative and operative treatment, including recent activity modification, medications, 
and home exercise program. Under consideration is a request for T9 to pelvis fusion and re-do laminectomy 
L1-S1 to address her spinal deformity. Evidence-based medical literature would support surgical intervention 
given her moderate to severe foraminal stenosis, lumbar degenerative scoliosis, and thoracolumbar kyphosis. 
Therefore, this request for multilevel lumbar fusion surgery is considered medically reasonable and 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 lumbar spinal fusion have been met. Therefore, we decided that the Plan has to 
pre-approve lumbar spinal fusion.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on September 13, 2019 
and billed under code G0483. 
 
You asked the Plan to pay for codes 80307 and G0483. In the documents sent to the Plan and as additional 
information directly to our office, you stated that this claim should be paid. The Plan denied your request. The 
Plan says while code 80307 was supported on appeal, code G0483 is not supported by the medical records as it 
does not give specific physician explanation for the need for this testing. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on September 13, 2019 and 
billed under code G0483.
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 20, 2020, to discharge. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay 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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 20, 
2020, forward as this patient was not shown to be a danger to themselves or others. The patient was not 
showing any auditory or visual hallucinations and was compliant with treatment while not showing any threats 
the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from October 20, 2020, to 
discharge.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic services. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have ongoing low back pain. It is noted that you have undergone 11 chiropractic 
treatments. No chiropractic chart notes were submitted. However, based upon the minor findings submitted on 
the chart note of August 19, 2020, and that you exhibit persistent back pain, there is no evidence that any 
chiropractic treatments have or will significantly alter the outcome. There is no evidence that clinical 
improvement has occurred or that further clinical improvement can reasonably be expected from ongoing 
chiropractic treatments. Therefore, you do not meet criteria for the requested chiropractic treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that you would like reconsideration because your doctor recommended compression stockings due to your condition.The Plan denied your request. The Plan says the compression stockings are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings overa qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.