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 when you are discharged you will have no one to 
care for you. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs 
can be provided at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for acute encephalopathy. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance angiography (MRA) of the head 
(70544) provided on January 31, 2022. 
 You asked the Plan to pay for an MRA of the head. You say that you have provided records to support the 
service rendered. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another 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, we have confirmed that code 70544 
is a column II code to column I code 70553. 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 a magnetic resonance angiography (MRA) of the head (70544) 
provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 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 admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical branch blocks (MBBs). 
 
You asked the Plan to pre-approve MBBs. You say that the enrollee is in a lot of pain and the need for these 
injection services is supported by the records provided. The Plan denied your request. The Plan says the 
requested injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when medically 
reasonable and necessary for patients who meet specific criteria.  
 
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 MBBs. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee would benefit from a 
sacroiliac joint injection. The clinical information does not indicate the need for facet joint injections. The 
review has determined that, specifically, there is evidence of non-facet pathology per clinical assessment or 
radiology studies that could explain the source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medical branch blocks (MBBs).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided from July 2, 2021, through July 31, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $0 copayment per day, for days 1 to 20 and a $184 copayment per day, for days 21 to 100 for 
skilled nursing facility care.  
 The enrollee has been asked to pay $2,760 ($184 copayment  x 15 days) for the skilled nursing facility care 
provided. The enrollee received a total of 37 days of skilled nursing facility care from two facilities. The Plan 
contract says that enrollees must pay a $0 copayment per day, for days 1 to 20 and a $184 copayment per day, 
for days 21 to 100 for skilled nursing facility care. The enrollee was asked to pay a copayment in the amount of 
$2,760 for 15 days of skilled nursing facility care which is less than the total of the applicable copayments for 
these services received. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled 
nursing facility (SNF) care provided from July 2, 2021, through July 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on December 18, 2021, billed with code 70450. 
 
You asked the Plan to pay for the CT scan interpretation. You say that this should be paid based on the records. 
The Plan denied your request. The Plan says the claim was not billed with the required 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 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 the interpretation of the computed tomography (CT) scan of the 
head provided on December 18, 2021, billed with code 70450.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for surgery provided on October 1, 2021. 
 
You asked the Plan to waive the coinsurance for surgery. You say that you are being billed for services which 
were unexpected. You state that you were at an in-network facility with prior authorizations. The Plan denied 
your request. The Plan says that you have been charged the correct coinsurance amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 35% coinsurance for Medicare-covered hospital stays days 
1-6. 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 did not provide information showing the allowed amount of this claim. 
Without knowing the allowed amount, we cannot determine whether the amount you are being asked to pay is 
appropriate for 35% coinsurance. Therefore, the Plan has not shown that its decision to ask you to pay 
$1,159.87 is correct or justified according to your contract with the Plan. Therefore, we decided that the Plan 
has to waive the coinsurance for surgery provided on October 1, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of neurostimulator electrode array, 
epidural (63650, L8680). 
 
You asked the Plan to pre-approve implantation of neurostimulator electrode array. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules for the requested services have not been met. 
 
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 implantation of neurostimulator 
electrode array. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee does not have an evidence-based 
indication for a spinal cord stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of neurostimulator electrode array have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantation of neurostimulator electrode array, epidural 
(63650, L8680).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet cabinet to administer therapy at home 
(E0694). 
 
You asked the Plan to pre-approve an ultraviolet cabinet. You say that you have been experiencing periodic 
occurrences of Granuloma Annulare. You have had visits with your doctor three times a week for months with 
very good results. You also say that you would like to request reconsideration for your treatment at home. The 
Plan denied your request. The Plan says you do not meet criteria for authorization of this device. 
 
 
 
 The Plan must follow Medicare rules. The rules say that an ultraviolet cabinet is covered for selected patients 
with generalized intractable psoriasis. Using appropriate consultation, the contractor should determine whether 
medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of 
a hospital. 
 
The records show that you have been receiving treatment at your providers office and doing well. The records 
also show that you do not meet criteria for an ultraviolet cabinet as the device is for convenience not medical 
necessity. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet cabinet to administer 
therapy at home (E0694).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on January 2, 2022, billed with code 70496. 
 
You asked the Plan to pay for the CT interpretation. You say that this should be paid. The Plan denied your 
request. The Plan says this was not billed with the necessary 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 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 the interpretation of the computed tomography (CT) scan of the 
head provided on January 2, 2022, billed with code 70496.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency anesthesia (99140) provided on August 20, 2021. 
 
You asked the Plan to pay for emergency anesthesia. You say that you have provided records to support the 
service rendered. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of emergency anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency anesthesia (99140) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician visit provided on December 10, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician visit. You say that the enrollee recently moved and wants to 
establish care. The Plan denied your request. The Plan says no prior authorization was obtained. 
 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 did not pre-approve the 
physician visit at issue. We found no exception that would require the Plan to pay for the physician visit. The 
records provided for review do not show that the physician visit was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the physician visit provided on December 10, 2021, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anesthesia services provided on January 17, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Anesthesia services. You say that you did not know the provider was OON. The 
Plan denied your request. The Plan says the provider is out-of-network and it was determined these services 
can be received in-network. 
 
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 Anesthesia services provided on January 17, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tacrolimus and prednisone tablets provided for 
immunosuppression on June 28, 2021. 
 
You asked the Plan to pay for the immunosuppressive drugs. You say that the documentation submitted is 
complete and supports payment. The Plan denied your request. The Plan says there is no itemized delivery 
ticket or proof of delivery in the file. 
 
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 not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the tacrolimus and prednisone tablets provided for 
immunosuppression on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair with multiple 
power options (K0861) and related features. 
 
You asked the Plan to pre-approve a replacement Group 3 power wheelchair. You say that the requested item is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
the requested item have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment.  
 
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 replacement Group 3 power 
wheelchair. Our reviewer says that the requested item is not medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee's present wheelchair has not reached its reasonable useful 
lifespan as defined by Medicare. The enrollee's current power wheelchair is reported to be less than 5 years old 
and no documentation is presented stating that it cannot be repaired. Additionally, based on the medical records 
provided, there is no documentation that the enrollee meets coverage criteria for power seating system E1007 
and a center mount power elevating leg rest E1012. Records do not document that the enrollee is at high risk 
for development of pressure ulcer; the enrollee has no current, or history of, pressure ulcers. The enrollee does 
not utilize intermittent catheterization for bladder management and does not have documented increased 
muscle tone or spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. You are requesting a replacement for a 
power wheelchair received by the enrollee in 2018. Therefore, the requested replacement is for an item that has 
not outlasted its reasonable useful lifetime. The requested electronic upgrades are not medically necessary. 
Based on this information, we decided that Medicare rules for coverage of a replacement Group 3 power 
wheelchair have not been met.  Therefore, we decided that the Plan does not have to pre-approve a replacement 
Group 3 power wheelchair with multiple power options (K0861) and related features.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living visit provided on June 10, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the assisted living visit. You say that it was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent 
or emergent. 
 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 the assisted living visit provided on June 10, 2021, 
by an OON provider.