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 enrollee is currently inpatient and requires more 
care. The Plan denied your request. The Plan says the records do not show that the enrollee needs to be seen by 
a rehabilitation doctor at least 3 times a week for evaluation of functional and medical goals and progress, or 
that the enrollee needs an intensive team for care. The Plan says that the services the enrollee needs can be 
provided safely in other settings. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on April 1, 
2022 and April 8, 2022, by an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that you are appealing the denial 
of services rendered on April 1, 2022 and April 8, 2022. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
 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 had network providers 
available who could have provided 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 subsequent nursing facility care visits provided on 
April 1, 2022 and April 8, 2022, by an OON provider.
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 appealing the denial of the authorization for 
admission to an acute inpatient rehabilitation facility. The Plan denied your request. The Plan says based on 
Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 enrollee has a medical history including diabetes mellitus, liver disease and 
peripheral vascular disease who was admitted to the hospital due to a right foot infection. The enrollee was 
treated surgically with partial foot amputation and medically with parental antibiotics. The enrollee has 
remained medically stable and does not require complex daily medical care. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 2, 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 May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) provided April 27, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford the cost of this service. 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 requested item or service was exhausted on date of service December 12, 2020. 
Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) 
provided April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revascularization, endovascular, open or percutaneous, 
tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes 
angioplasty within the same vessel, when performed (37231) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this procedure needs to be performed because 
the enrollee is in pain. The Plan denied your request. The Plan says that records do not show that the enrollee 
has hemodynamically significant peripheral arterial disease. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has a 
history of healed ulcers of the lower extremities bilaterally. There is no objective documentation of perfusion 
such as arterial Dopplers with ABIs and waveforms. The patient has, however, demonstrated that she had 
sufficient perfusion to heal her lower extremity ulcers. As the patient has a history of sacral decubitus ulcers 
and is nonverbal it is likely that she is also non-ambulatory. There is no documentation of a femoral pulse examination and no noninvasive study of her aortoiliac arteries (patient with sacral ulcer). Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, 
initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same 
vessel, when performed (37231) for the enrollee.
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You can 
receive further services 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health physical therapy visits. 
 
You asked the Plan to pre-approve 2 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the appeal was received after the enrollee's plan 
termination date. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a plan is legally responsible under its contract 
and the regulations to authorize, provide, or pay for all Medicare covered services or prescription drugs that are 
denied and upon appeal are found to be services the plan should have authorized, provided, or paid for its 
enrollees. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 2 home health physical therapy visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 2 home health physical therapy visits.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 37187. We decided that the Plan does not have to pay for CPT 
37248 and CPT 37249.  
 
You asked the Plan to pay for vascular surgical services provided to the enrollee on January 13, 2022. You say 
that this should be paid for. The Plan says that the denied codes are not supported by the records submitted. 
 
We decided that the Plan has to pay for CPT 37187.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 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 for CPT 37187 Our reviewer says that that there is 
satisfactory documentation that the patient underwent bilateral percutaneous venous catheter-based 
thrombectomy.  There is documentation of residual thrombus burden in the iliac veins bilaterally and the 
AngioJet device was used bilaterally. The documentation meets the minimum threshold for coverage of 
bilateral venous thrombectomy day 1. Although the patient had lysis earlier the same admission, this was the 
first catheter-based thrombectomy. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
37187.  
 
We also decided that the Plan does not have to pay for CPT 37248 and 37249. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 37248 and 37249. Our reviewer says that the 
documentation does not support coverage of venous angioplasty of one vein and an additional vein. Coverage 
of these codes requires, at the minimum, a description of the degree of stenosis in the veins treated and the post 
angioplasty result. As these minimal elements have not been provided, the necessity and appropriateness of the 
angioplasties cannot be determined and therefore unable to overturn the health plan's determination.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37248 and 37249 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37248 and 37249. 
 
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: 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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has stabilized medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed 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: 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 requesting reconsideration as the case was 
denied because peer to peer couldn't be completed and are attaching the current clinicals The Plan denied your 
request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval. 
 
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 enrollee has a medical history including hypertension, hyperlipidemia and 
metastatic breast cancer who was admitted to the hospital due to a bowel obstruction with pain. The enrollee 
was treated surgically with bowel resection and a colostomy. The enrollee also has bilateral pleural effusions 
that are concerning for cancer. She has stabilized medically and does not require complex daily medical care. 
The most recent therapy notes indicate that the enrollee is able to ambulate household distances using a walker 
with minimal assistance. Fatigue and shortness of breath have made progress with therapy difficult. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on March 14, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on March 29, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you spoke with an insurance agent in the 
beginning of March 2022, and were advised that the hearing aids were covered. You also say that you were told 
the treating provider was in-network. The Plan denied your request. The Plan says the treating provider is not 
part of the Plan's hearing network. The Plan also says you were advised that you must use a Plan approved 
hearing provider when you contacted the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor. 
 
 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The treating provider is not a Plan-approved hearing aid vendor. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on March 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting provided on May 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that it took two visits to complete the eye exam. 
The Plan denied your request. The Plan says the information does not support the need for this many services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 We looked at the file and the Plan's rules. The file shows that you previously received routine vision care on 
January 26, 2022. Your plan only convers one routine vision exam per year. Based on this information, we 
decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the contact lens fitting provided on May 17, 2022.