Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchial thermoplasty (31622, 31660, 31661). 
 
You asked the Plan to pre-approve bronchial thermoplasty. You say that the requested procedure has the 
potential to help decrease the severity of the enrollee's symptoms. You also say that this would be cost effective 
for the Plan to approve this treatment. The Plan denied your request. The Plan says the requested treatment 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 bronchial thermoplasty. Our reviewer 
says that the requested bronchial thermoplasty (BT) is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the BT studies do not include participates with similar clinical 
conditions to the enrollee in this case. Therefore, the reviewer found that the requested procedure 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 bronchial thermoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bronchial thermoplasty (31622, 31660, 31661).
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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary; you can receive the care you need at a skilled nursing 
facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power 
wheelchair. 
 
You asked the Plan to pre-approve an electronic connection. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item 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 an electronic connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested interface is not medically necessary for the enrollee, who has normal or near-
normal hand and grip strength. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D6058) and a pontic (D6245) for tooth #8 provided 
on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that these dental procedures should be covered and 
go towards your maximum coverage allowance. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because crowns and major restorations are not covered by the Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D6058) and a pontic (D6245) for tooth #8 provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services represented by codes 81408 and 81351 
billed for date of service July 10, 2021. 
 
You asked the Plan to pay for codes 81408 and 81351. You say that the records provided support payment for 
the codes which remain in dispute. The Plan denied your request. The Plan says the services which are still 
denied are not supported.  
The Plan must follow Medicare rules. Medicare rules say that procedures reported together must be both 
medically reasonable and necessary and ordered by the physician who is treating the beneficiary and using the 
results in the management of the beneficiary's specific medical problem. 
 
We looked at the file and Medicare rules. We found that the medical records provided included a physician 
order for a "comprehensive neurogenerative disease panel" with no additional supporting documentation. There 
is no documentation of a medical indication for the treating provider to support the tier 1 or tier 2 molecular 
testing billed by the laboratory. Based on this information, we decided that Medicare rules for coverage of 
codes 81408 and 81351 have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services represented by codes 81408 and 81351 billed for date of service July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a one hundred (100) day supply of test strips (CPT code 
A4253). 
 
You asked the Plan to pre-approve the supplies. You say that the supplies are necessary. The Plan denied your 
request. The Plan says the supplies are not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. The item was requested above 
normal dispensing limits- as a 100-day supply. The item is available as a recurring 90-day supply. Therefore, 
we decided that the Plan does not have to pre-approve a one hundred (100) day supply of test strips (CPT code 
A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care from October 28, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient mental health 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 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 inpatient mental health care. Our 
physician reviewer found the admission of this enrollee does not meet the criteria for October 28, 2022, 
forward as this enrollee was not shown to be a danger to themselves or others, delusions, auditory or visual 
hallucinations noted. The enrollee was cooperative/compliant with treatment while not showing any threats the 
safety as the enrollee awaits placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care from October 28, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that a separately identifiable interpretation is 
entitled to payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 62270. 
 
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 93042 
is a column II code to column I code 62270. CPT code 93042 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 93042 billed for date of service April 8, 2022.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
COVID-19. 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 the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that this drug is to be used for prevention and 
treatment of chemotherapy related nausea. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for coverage under Part B. 
 
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 Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 17, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee meets guideline criteria 
for admission to inpatient care for neurological finding requiring inpatient care as indicated by weakness that 
was progressive or severe. We believe the admission was medically necessary and we are still requesting full 
reimbursement for this case. The Plan denied your request. The Plan says the requested services were 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 pay for 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 the inpatient admission was not medically necessary for the enrollee. Inpatient care is 
necessary when the enrollee's signs and symptoms and general medical condition can only be managed safely 
in an acute inpatient setting, when the enrollee requires diagnostic studies in an inpatient setting, or if it is 
medically necessary for the enrollee to remain in the acute inpatient setting. In this case, the enrollee was 
admitted in stable condition and could have been treated at a lower level of care. He was treated with oral pain 
medications effectively and there was no active infection or injury that would require inpatient management. 
 
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 pay for the acute inpatient hospital care provided March 17, 2022, to March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for services provided on May 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the service was not billed as required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99153 is a technical component only code. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99153 billed for services provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional chiropractic visits. 
 
You asked the Plan to pre-approve eight (8) additional chiropractic visits. You say that the chiropractic services 
should be covered because you have pain to the left trapezius, mid back, buttocks and back of your right hand. 
The Plan denied your request. The Plan says Milliman Clinical Guidelines (MCG) discusses the rehabilitation 
of cases such as this and the expected level of service to reasonably transition successfully to a home exercise 
program based on the evidenced based medical literature which should be achievable with 10-12 approved 
chiropractic visits. 
 
The Plan follows Medicare rules. Medicare rules say that the treatment is considered maintenance therapy 
when additional clinical advancement cannot logically be expected from constant ongoing care and the 
chiropractic treatment becomes auxiliary rather than curative in nature. 
 
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 eight (8) additional chiropractic visits. 
Our reviewer says that additional chiropractic visits are not medically necessary. Our physician reviewer found 
that the case file contains 23 chiropractic notes that span from February 16, 2022 through August 11, 2022. 
During that time, there is no reduction in the subjective reports of pain. The chiropractic services in this case do 
not support a reasonable expectation of recovery or improvement of function. When further clinical 
improvement cannot be reasonably expected from ongoing care, the care is considered maintenance. The rules 
say that Medicare does not cover chiropractic maintenance 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 eight (8) additional chiropractic visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve eight (8) additional chiropractic visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on September 23, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is 
payable per patient per hospital stay. 
 
We looked at the file and Medicare rules. The file shows that one hospital discharge code was previously paid 
for this hospital stay. 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 pay for the hospital discharge services 
rendered on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99156, & 99157 provided on February 16, 
2021. 
 
You asked the Plan to pay for procedure codes 99156, & 99157. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 codes 
99156, & 99157 are column II codes to column I code 64635 with a modifier indicator of 0. The column II 
codes are 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 codes 99156, & 99157 provided on 
February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for an evaluation and 
treatment. The Plan denied your request. The Plan says utilization of network providers and authorization for 
certain services is required. 
 
 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 services provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology testing billed for services provided on 
September 1, 2021. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the services. The 
Plan denied your request. The Plan says authenticated records were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. In this case, medical records were not provided. There were no 
results of the pathology testing and no records from the enrollees treating physician. The file shows that the 
Plan made several attempts to obtain additional information without success. Based on this information, we 
decided that the Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does 
not have to pay for the pathology testing billed for services provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone, and your providers and family all 
recommend IRF services. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.