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

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no medical issues that require treatment at this level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a 
review of the records provided, it is not expected that this enrollee would improve in a reasonable period of 
time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory 
or visual hallucinations. The enrollee is compliant with treatment while not showing any acute threats to safety. 
It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient 
level of care rather than a lower level of care beyond the dates in question. The health plan's denial of 
continued inpatient psychiatric services is 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that based on the clinical information provided to us you tolerate a BiPAP device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. The record indicates that you have acute and 
chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
BiPAP with average volume-assured pressure support (AVAPS) settings is being ordered. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the device selected. You can be treated with a BiPAP machine with AVAPS capability.  Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81223, 81302, 81330, 81332, 81345, 
81404, 81405, 81406, 81407, 81408) rendered by the out-of-network (OON) provider on October 1, 2020. 

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81223, 81302, 81330, 81332, 81345, 81404, 81405, 
81406, 81407, 81408) rendered by the out-of-network (OON) provider on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on April 
26, 2021. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you were supposed to receive this 
service during the 2020 plan year, but this service was pushed back because of the pandemic. You also say that 
you would like this service to be covered. The Plan denied your request. The Plan says the annual maximum 
benefit provision of your benefit plan was reached. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on January 26, 2021 and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
mandibular partial denture (D5214) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says scaling and root planing is not listed as a covered service. 
 
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 scaling and root planing 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover treatments that are considered experimental or 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure remains experimental for the treatment of low back pain. More research is needed to show 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve basivertebral nerve ablation for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 26 to 
June 28, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy services. You say that your outstanding balance is incorrect. The 
Plan denied your request. The Plan says rules for out-of-network care have not been met. 
 
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 psychotherapy services (90832) provided on 
March 26 to June 28, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a total 
knee arthroplasty procedure (27487). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you have had multiple surgeries 
and will be unable to get home after your upcoming procedure. The Plan denied your request. The Plan says the 
requested inpatient admission and services are not medically necessary with the approved total knee 
arthroplasty procedure. There is no documentation provided to support the expectation that you will require a 
greater than two midnight stay. The procedure can be performed in an ambulatory setting. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found you are medically stable. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation that you will require a 
greater than two midnight stay. The review has determined that the record does not show that at the time of 
inpatient admission the admitting physician reasonably expects your necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 pre-approve acute inpatient hospital care to be provided with a total knee arthroplasty 
procedure (27487).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray exam (71045) provided on February 3, 2021. 
 
You asked the Plan to pay for X-Ray 71045. You say that you are appealing with records to support the level of 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
code 71045 has a procedure-to-procedure (PTP) edit with code 36556 so is not separately payable without an 
appropriate modifier. 

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 X-Ray 
71045 is a column II code to column I code 36556. 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 an X-Ray exam (71045) provided on February 3, 2021.
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 does not meet 
criteria. 
 
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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
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 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 daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to 
have reached a new plateau in function. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81270, G0452) provided on March 31, 
2021. 
 You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says there is not a physician order for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patient?s illness or injury (or symptom or complaint) and ordered by a physician. 
 
We looked at the file and Medicare rules. The submitted records do not include a physician order for the testing 
at issue. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81270, G0452) 
provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthotic device (L8702). 
 
You asked the Plan to pre-approve the MyoPro Orthotic. You say that the device is necessary. The Plan denied 
your request. The Plan says this device is considered to be 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 the MyoPro Orthotic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found requested device is not reasonable and necessary for the diagnosis or treatment of an 
illness or injury or to improve the functioning of a malformed body member. There is insufficient evidence in 
the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve 
hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. 
 
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 MyoPro Orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro Orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair 
 
You asked the Plan to pre-approve the group three power wheelchair. You say that the extended features are 
necessary. The Plan denied your request. The Plan says the documentation does not show that the enrollee 
meets coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that say that to qualify for a group 3 power wheelchair 
with Multiple Power Options, there must be medical need for a ventilator or for two power options: power tilt 
and power recline. 
 
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 group three power wheelchair. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not 
meet criteria for power tilt and power recline system as there was no indication the patient would not be 
appropriate for a standard wheelchair with appropriate cushions and foot rests in the setting of the nursing 
home where she would receive assistance for functioning and mobility. 
 
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 group three power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair power recline.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heavy duty wheelchair (CPT code K0006) and gel or 
gel-like pressure pad for mattress, standard mattress length and width (CPT code E0185), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee is obese and the previous chair they had 
was not sustainable and was damaged. You state that the enrollee has some issues on their knee and was just 
released from the hospital and is in need of this heavy-duty wheelchair and gel like pressure pad for mattress. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee meets all of the 
following criteria for the heavy-duty wheelchair: Based on the medical records provided there is no 
documentation that the enrollee meets all of the following criteria for the gel like pressure pad. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve heavy duty wheelchair (CPT code K0006) and gel or gel-like pressure pad for mattress, standard 
mattress length and width (CPT code E0185), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on February 22, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this code is a bundled service. 
 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 99100 
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 anesthesia services (99100) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be rendered by the OON provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be rendered by the OON provider.