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

 
We decided that the Plan does not have to approve the acute inpatient hospital level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the total knee replacement is approved but the inpatient admission is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found that the enrollee is approved for a right total knee arthroplasty. The procedure is not on the inpatient-only 
list. The records do not support that she has any poorly-controlled comorbid conditions that would prevent her 
from having the elective surgery. The records do not show that the enrollee will require at least two midnights 
of inpatient hospital care for the approved procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital level of care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. Skilled therapies at home or at a skilled 
nursing facility may be approved upon request. 
 
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 the enrollee has 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that this is needed for the enrollee to 
complete mobility-related activities of daily living. The Plan denied your request. The Plan says this is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 23, 2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you think that this 
service should be covered. 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). Your contract with the Plan clearly says that you must pay a $195 
copayment per day, for days 1-7, for inpatient hospital services. 

You have been asked to pay a $585 copayment for the inpatient hospital stay ($195 x 3 days = $585). This 
item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided from July 23, 2022, to July 26, 2022.
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 has already failed at a lower 
level of care and requires prolonged hospitalization, including intensive skilled services offered in the LTAC 
setting. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a skilled nursing 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 enrollee was admitted with pleural effusion. The record indicates that the enrollee 
has ongoing acute medical issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied.  
 
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: 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 are at risk for having another stroke which 
makes it harder for you to get out of bed. The Plan denied your request. The Plan says an IRF admission 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 that you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service November 23, 
2022.
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee's 
needs are being met at the current hospital location. 
 
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 was admitted for scheduled cystoscopy and installation of mitomycin 
into the left renal pelvis which was complicated by cardiac arrest. The record indicates that the enrollee has 
ongoing medical issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99457 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 99457. You say that this is a covered service and should be paid. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. The 
Plan has already paid for one unit of this code on August 17, 2022 (this is a code that is charged monthly). 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99457 is 1. The MAI value for this code is 2. You billed two units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99457 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99457 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2022, billed with 
codes 81314 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 2, 2022, billed with codes 81314 and 81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics - porcelain fused to high noble metal 
(D6240). 
 
You asked the Plan to pre-approve the dental services. You say that you need this service in order to be able to 
eat and chew. 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 that the Plan has already approved three retainer crowns (D6750) which are in the same benefit category as the pontics. The approved retainer crowns will exhaust your fixed prosthodontic benefit. Therefore, we 
decided that the Plan does not have to pre-approve two pontics - porcelain fused to high noble metal (D6240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
13, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9541 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for procedure code A9541. You say that this service was billed correctly. The Plan 
denied your request. The Plan says payment for code A9541 is bundled into payment for code 78264.  

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 A9541 
is a column II code to column I code 78264 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 procedure code A9541 billed for date of service December 7, 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 admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 the enrollee has 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 27, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 81355 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 27, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 
81335, 81355 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery tooth #29 (D3431). 
 
You asked the Plan to pre-approve code D3431. You say that you requested a root canal with your dentist. You 
also say the dentist informed you that the Plan is not covering the medicine. The Plan denied your request. The 
Plan says this service is not covered under your benefit plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery tooth 
#29 (D3431).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a below knee flex cover system (L5962). 
 
You asked the Plan to pre-approve a below knee flex cover system. You say that the enrollee's physical state 
exceeds the performance of a regular foot or ankle. You also say that the enrollee's vocational responsibilities 
necessitate use of a more advanced foot in order to carry them out safely. The Plan denied your request. The 
Plan says that that the records provided do not indicate that the enrollee is exposed to harsh conditions or 
engages in extraordinary activities that require extra protection from a specialized prosthetic cover. 
 
The Plan follows Medicare rules. Medicare rules say that specialized protective outer surface covering systems 
may be covered when a beneficiary who has 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 cover. 
 
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 below knee flex cover system. Our 
reviewer says that the requested below knee flex cover system is medically reasonable and necessary. Our 
physician reviewer found the provided documentation does not indicate that the enrollee is in a harsh 
environment. However, the enrollee is involved in extraordinary activities and exposed to the elements during 
his football coaching activities. Therefore, the reviewer found that a below knee flex cover system is medically 
reasonable and necessary 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 a below knee flex cover system have been met. Therefore, we decided that the 
Plan has to pre-approve a below knee flex cover system (L5962).  
 
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.