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 requested admission to an IRF 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 in the Medicare rules section. 
 
   
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 clinical documentation shows that the enrollee has active medical comorbidities, 
and the enrollee has functional impairments requiring physical therapy, occupational therapy, and speech 
therapy however there is no IRF compliant diagnosis or clinical reasoning documented why the enrollee's 
functional impairments are complex enough to warrant interdisciplinary team management or intense therapy 
related to debility (or how documented dysphagia is related to this rehabilitation diagnosis). 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of the left knee with Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane for the left knee. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a repeat series of injections may be allowed when the 
conditions listed in the Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Durolane for the left knee have not been met. Specifically, the case record indicates that a previous 
injection in the same location was given within the past six months. Therefore, we decided that the Plan does 
not have to pre-approve treatment of the left knee with Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface cover (L5962). 
 
You asked the Plan to pre-approve a flexible protective outer surface cover. You say that the requested item is 
a medical necessity for you. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 a flexible protective outer surface 
cover. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the specialized lower limb prosthetic cover (L5962) exceeds your 
medical needs. The documentation does not support that you have special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the 
level of protection that is afforded by a standard prosthetic cover. 
 
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 flexible protective outer surface cover have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a flexible protective outer surface cover (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services (procedure code 97598) provided to the 
enrollee on May 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare coding guidelines were not met. 
 
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, we have confirmed that code 97598 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for debridement services (procedure code 97598) provided to the enrollee on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64640-XS billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 64640-XS. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the available records do not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64640-XS is "Destruction by neurolytic agent; other peripheral nerve or branch." 
 
We asked our coder 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 procedure code 64640-XS. Our reviewer says that the 
procedure code at issue does not meet criteria for reimbursement. Our reviewer found that the available 
documentation does not support a third unit of procedure code 64640. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64640-XS have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64640-XS billed for date of service May 19, 2022.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and are able to be furnished safely and effectively 
only on an inpatient basis. All medically necessary care is being provided in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
pulp vitality tests (D0460) provided on February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral exam was exhausted on date of service January 18, 2022. Your dental 
benefit does not include pulp vitality tests.  Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) and pulp vitality tests (D0460) provided on February 2, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to return home. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of thoracic spine 
without contrast (72146). 
 
You asked the Plan to pre-approve an MRI of thoracic spine without contrast. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria 
for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of thoracic spine without 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
no clear documentation of a trial of physical therapy, which would be needed for back pain before advanced 
imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of thoracic spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of thoracic spine 
without contrast (72146).
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 need inpatient rehabilitation to regain maximum 
function. The Plan denied your request. The Plan says the services you need can be provided safely in other 
settings, for example, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 procedure code 99100 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings-four radiographic images (code D0274) provided 
on May 2, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. The frequency has been exceeded per the EOC based 
on bitewings received on October 22, 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 22, 2021. 
Therefore, we decided that the Plan does not have to pay for bitewings-four radiographic images (code D0274) 
provided on May 2, 2022.
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 need additional care and treatment. The Plan 
denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 
 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 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 the medical services coded 93016 provided on October 6, 
2021. 
 
You asked the Plan to pay for the medical services coded 93016. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says no separate payment can 
be made for this code. 
 
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, we have confirmed that code 93016 
is a column II code to column I code 93015 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the medical services coded 93016 provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of congenital 
interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant (93580). 
 
You asked the Plan to pre-approve a transcatheter closure. You say that you understand that the procedure was 
denied due to the enrollee's age, however given her two separate cryptogenic cerebrovascular accidents, we 
would like to ask that you reconsider the decision to deny the closure for the enrollee. The Plan denied your 
request. The Plan says as the enrollee has a significantly increased risk from PFO closure and the literature and 
guidelines suggest minimal or no evidence of benefit, the requested PFO closure for the enrollee is not 
medically necessary. 
 
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 a transcatheter closure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a right-sided stroke in 5/2022, with subsequent new right-sided 
symptoms. Transesophageal echocardiogram showed a PFO with bidirectional flow. RoPE is not elevated. 
Clinical studies have shown significantly higher per-procedural complications in older age groups; hence 
guidelines do not recommend PFO closure in patients over age 60. As such, guidelines would not support the 
need for a PFO closure device. In summary, there is insufficient documentation to support the medical 
necessity for the requested PFO closure in the enrollee's clinical management. 
 
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 transcatheter closure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous transcatheter closure of congenital interatrial communication (i.e., 
Fontan fenestration, atrial septal defect) with implant (93580).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received from providers. The 
Plan denied your request. The Plan says the specimen was obtained in an office setting. 
 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an inpatient hospital stay from June 13, 
2022, to June 18, 2022. 
 
You asked the Plan to reduce the cost share for an inpatient hospital stay. You say that the enrollee should only 
be responsible to pay the emergency room cost share for June 13, 2022, and June 14, 2022. The Plan denied 
your request. The Plan says this cost sharing was charged 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 enrollees contract with the Plan clearly says that enrollees 
must pay a $390 copayment for each day in an in-network hospital for the first 5 days; $0 for each day after 
day 5 for each inpatient stay.  
 
The enrollee has been asked to pay $1,950 for an inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the cost share for an 
inpatient hospital stay from June 13, 2022, to June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 3, 2022.