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. The Plan denied your request. The Plan says the enrollee does not 
require an intensive level of therapy requiring physician oversight. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 an office visit, debridement, and wound compression 
bandage application provided on September 6, 2022, by OON provider. 
 
You asked the Plan to pay for an office visit, debridement, and wound compression bandage application. You 
say that the codes submitted are covered under the enrollee's insurance. The Plan denied your request. The Plan 
says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit, debridement, and wound 
compression bandage application provided on September 6, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinacalcet HCl. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cinacalcet HCl.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (scooter) (K0806) 
and wheelchair component or accessory (cup and cane holder) (K0108). 
 
You asked the Plan to pre-approve a scooter and cup and cane holder. You say that the documentation supports 
the enrollee receiving a scooter to aid them with mobility limitations. The Plan denied your request. The Plan 
says this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV (codes K0806, K0807, or 
K0808) is provided it will be denied as not reasonable and necessary. Medicare rules also say if the PWC base 
is not covered, then related accessories will be denied. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a scooter and cup and cane holder have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power operated vehicle (scooter) (K0806) and wheelchair component or 
accessory (cup and cane holder) (K0108).
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's esophagus is reassessed 
and, on a ventilator, as well and heart stopped while in care, the enrollee needs rehabilitation at LTACH. The 
Plan denied your request. The Plan says the enrollee's records do not show you need continued treatments and 
care that can only be given in a hospital setting, when ready to leave the hospital medically necessary care may 
be provided safely in a different level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (electrodes) (A4595) provided on 
August 27, 2022. 
 
You asked the Plan to pay for the electrodes. You say that it is impossible for the enrollee to initiate and 
continue treatment without prescribed supplies (A4595) as device's design function for treatment require said 
supplies for regimen. The Plan denied your request. The Plan says that code A4595 is not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery for the supplies provided in this case. Specifically, there was 
a tracking slip from the United States Postal Service (USPS) and a packing slip from the provider which shows 
exactly what item was shipped. These documents contain the same tracking number, and therefore, is valid 
proof of delivery. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies 
(electrodes) (A4595) provided on August 27, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb stimulator of peripheral nerves 
of the wrist (Cala Trio device) (K1018). 
 
You asked the Plan to pre-approve Cala Trio device. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested device 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 Cala Trio device. Our reviewer says 
that the requested Cala Trio device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation is not sufficient to support the medical necessity of the 
requested Cala Trio device. Therefore, the requested device is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb stimulator of peripheral nerves of the wrist (Cala Trio device) 
(K1018).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on October 2, 2021 to 
October 4, 2021. 
 
You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed 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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
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 99223. Our reviewer says that code 99223 is 
not supported. Our reviewer found an extended history of present illness requires documentation of four elements of the following: location, duration, quality, severity, timing, associated signs and symptoms and 
modifying factors. Provided records in this case do not document four elements in the history of present illness; 
two elements are documented in the provided records. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on October 2, 2021 to October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says that the request for the IRF level of care exceeds your medical needs. 
 
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 found to be medically reasonable and necessary. Our physician reviewer found that you 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. You require supervision for grooming. You require maximum assistance for lower body 
dressing and minimum assistance for transfers. You are ambulating 15 feet with a walker with stand by 
assistance. You have had a decline from her baseline level of function and would benefit from the intensity of 
therapies provided on acute inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission is 
medically necessary. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart (J9332). 
 
You asked the Plan to pre-approve Vyvgart. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Vyvgart. Our reviewer says that this 
drug is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of myasthenia gravis, acetylcholine receptor antibody positive. The Food and Drug Administration has stated 
that the requested drug is approved as the originator biological product for the treatment of generalized 
myasthenia gravis in adult patients who are anti-acetylcholine receptor (AChR) antibody positive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have not been met. Therefore, we decided that the Plan has to pre-
approve Vyvgart (J9332).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam dressing wound cover (A6212) December 9, 2021. 
 
You asked the Plan to pay for the foam dressing wound cover. You say that this claim should be paid. The Plan 
denied your request. The Plan says services/supplies are not separately reimbursable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the foam dressing wound cover was used in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pay for the foam dressing wound cover (A6212) December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for patients that 
do not receive adequate relief from traditional conservative methods. The Plan denied your request. The Plan 
says this 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on May 10, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on May 10, 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 LTACH is the most appropriate level of 
care for the enrollee. The Plan denied your request. The Plan says the enrollee can remain in the current acute 
care location until such time no further acute level care is needed, a discharge to a lower level of care would 
not be appropriate if the member has ongoing acute care needs. 
 
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 is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital.  
 
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: Other
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray coded 74018 provided on May 19, 2022. 
 
You asked the Plan to pay for the x-ray. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that this is an unbundled service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that this is an unbundled service. The documentation did not 
include Medicare rules or an explanation on why this service is an unbundled service. Therefore, we decided 
that the Plan has to pay for the x-ray coded 74018 provided on May 19, 2022.  
 
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.