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 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 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 based on the medical records provided 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 do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical 
records provided there no documentation that you require the intensive rehabilitation therapy program provided 
in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in 
this case. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for magnetic resonance angiographies 
(MRA's) provided on June 26, 2020, and July 13, 2020. 
 
You asked the Plan to waive the coinsurance for MRA's. You say that you were told that you would only owe a 
$55 copayment. 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 20% 
coinsurance for diagnostic imaging.  
 
You received an MRA on June 26, 2020. The total allowed amount is $396.21 and 20% of that is 79.24.  
 
You received an MRA on July 13, 2020. The total allowed amount is $471.52 and 20% of that is $94.30. 
 
The total amount you owe is: $173.54.  
 
You have been asked to pay the total coinsurance amount of $173.54 for MRA's. MRA's 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 coinsurance for magnetic resonance angiographies (MRA's) provided on June 26, 2020, and July 
13, 2020.
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 the SNF admission. You say that the enrollee requires SNF care as she is 
not able to stand on her own. The Plan denied your request. The Plan says the enrollee's issues are chronic in 
nature and not likely to improve with daily skilled services. Her needs are mainly custodial. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees 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 SNF admission 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 pre-approve the new patient office or other outpatient visit (99201) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you have a prior 
history with the out-of-network provider. The Plan denied your request. The Plan says breast evaluation 
services are available to you and can be received from providers in the preferred network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office or other outpatient visit (99201) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) 
(K0553, K0554). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says you do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered by 
Medicare when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The records do not show that you are insulin-treated with three or 
more daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM) (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system (E2300).You asked the Plan to pre-approvethe power seat elevation system. You say that the records provided support the need for the requested power seat elevation system.The Plan denied your request. The Plan says the enrollee's condition doesn't meet the rules for approval.The Plan follows Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules also say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.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 power seat elevation system. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records provided show that there is documentation of the enrollee's wheelchair having an electrical connection device described by code E2310 or E2311. Our physician reviewer found that the medical records show that the sole function of the connection isfor a power seat elevation or power standing feature. The requested system is not considered medically necessary, as it is not primarily medical in nature. 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 power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 7, 
2020 and billed under code 95907. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 95907 was not documented in the narrative of the operative report.  The Plan states 
that F-waves are incomplete nerve studies when done alone without the motor study. The operative report 
clearly states that baselines were not established. This code is used to establish baselines. They have no proven 
value for intra-operative spine monitoring. As a result, the requested procedure code is not substantiated by the 
clinical documentation in the technical report submitted for review.  
 
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, code 95907 is not supported by the 
records provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the 
Plan does not have to pay for physician services provided to the enrollee on January 7, 2020 and billed under 
code 95907.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer procedure. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869). You say that the enrollee is suffering and needs this procedure. The Plan denied your request. The 
Plan says the Superion interspinous spacer procedure is considered experimental and investigational. 
 
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 insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA 
indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with 
moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
This enrollee has mild neuroforaminal stenosis reported by the radiologist, and would not meet FDA 
indications. Superion indirect lumbar decompression would not be considered the standard of care for the 
enrollee's medical condition. 
 
 
 
Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of 
this enrollee's medical condition. Our physician reviewer found current evidence based medical guideline and 
peer reviewed literature do not fully support the spinal decompression device procedure over the gold 
standard of lumbar laminectomy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion 
interspinous spacer procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup. 
 
You asked the Plan to pre-approve the core buildup. You say that the teeth will need a build-up to create a solid 
structure. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core 
buildup.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 7, 
2020. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you disagree with the charges 
because the procedure was short and you will likely require more. 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 $100 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $100 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 a laryngoscopy provided on 
January 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97163) provided on July 19, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed 
code does not appropriately reflect the services rendered by the physical therapy assistant. 
 
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 physical therapy assistant 
shall not be billed as services incident to a physician/NPP's service. 
 
In this case, the CPT Code Manual definition of code 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family.  
 
We find that CPT code 97163 is not supported in the record. Specifically, the record indicates that these 
services were rendered by a physical therapy assistant. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for physical therapy services (97163) provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physiologic study you had on May 4, 
2020, and the Duplex scan you had on May 6, 2020. 
 
You asked the Plan to waive the copayments for the physiologic study and the Duplex scan. You say that these 
tests are not radiology tests, so you should have a lower copayment. The Plan denied your request. The Plan 
says you were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $100 copayment for radiological diagnostic services.  
 
The enrollee has been asked to pay a $100 copayment for the physiologic study and the Duplex scan. The 
physiologic study and the Duplex scan fall within the radiological diagnostic services benefit category. This is 
because the physiologic study uses Doppler waveforms in order to produce test results and the Duplex scan 
uses ultrasound technology.  These two tests are considered radiological procedures because both tests use 
imaging technology. This means that you have been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayments for the physiologic study you had on May 4, 
2020, and the Duplex scan you had on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
October 11, 2019 to November 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that he nursing home was only 
provided Medicaid as the patient's insurance and they were not aware that the patient had Medicare until the 
claim was denied by Medicaid. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services rendered by an out-of-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 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 subsequent nursing facility care (99308) 
provided on October 11, 2019 to November 14, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from 
September 25, 2020, to discharge. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required 
skilled rehab services to improve function due to weakness and deconditioning.  There were no skilled nursing 
needs. As of September 15, 2020, the enrollee did not require any skilled nursing or rehab services on a daily 
basis. The enrollee was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require 
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
 
 
The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. 
The enrollee received skilled care and improved, however the enrollee's function had plateaued by September 
24, 2020, and the enrollee did not require any further inpatient skilled rehab services. The enrollee's function 
was at or near their prior level of function and they could be discharged to a lower level of care for further 
services. During the point-of-care under review the enrollee required custodial services. The denial for further 
inpatient skilled care is upheld. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care provided to the enrollee from September 25, 2020, to discharge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve the additional mileage. The Plan denied your request. The Plan says this 
exceeds the 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 routine transportation trips up to 30 miles from pick-up point to destination point.  
 
We looked at your request, the records in the case file, and the rules. The requested additional mileage will 
exceed the Plan's benefit limit for overage of routine transportation. Based on this information, we decided that 
the Plan's rules for coverage of the requested routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional mileage for routine transportation trips.