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 IRF services 
requested do not meet the requirements for approval. The services the enrollee needs may be provided safely in 
other settings, for example, a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
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 is medically stable and does not need a rehabilitation physicians close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. No rehab nursing needs identified or documented. The enrollee needs PT and 
OT in a subacute rehab. 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: 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 the enrollee is presently at fall risk and the 
combination of significant physical and occupational therapy on a daily basis would greatly assist the enrollee 
to return to life at home. The Plan denied your request. The Plan says based on Medicare guidelines the 
inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs are identified 
or documented.  At the current functional level the enrollee does not need 3 hours a day x 5 days a week of 
therapies with multidisciplinary approach in an IRF. The documentation does not support medical necessity for 
admission to an IRF.  The enrollee has no current medical complexity or rehabilitation nursing needs. While 
the enrollee will benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely 
met in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on August 10, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for X-rays. 
 
You have been asked to pay a $50 copayment for x-ray. This item/service falls within the X-rays benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You have been 
asked to pay $44.92 which is less than the standard $50 copayment for an x-ray. Therefore, we decided that the 
Plan does not have to waive the copayment for x-ray provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulations (TENS) 
device (E0730), provided on June 5, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was not ordered by the enrollee's treating physician. 
 
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 physician order for the supplies provided in this case. The enrollee's 
treating physician confirmed they did not order this item. 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 transcutaneous electrical nerve stimulations (TENS) device (E0730), provided on June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99316) provided August 9, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99316 is nursing facility discharge day management; 
more than 30 minutes 
 
We find that CPT code 99316 is not supported in the medical record. Specifically, there is no discharge note in 
the record for this date of service. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99316) provided August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 ventilator. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication of the mode of operation of the device requested. 
 
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 device. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the Life2000 System has not been shown in high quality studies to be of benefit in the treatment of chronic 
obstructive pulmonary disease (COPD). It is not a true ventilator because it is not capable of providing full 
ventilatory support. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Life2000 ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power elevating leg rest/platform (E1012), and 
electronic connection between wheelchair controller and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the power wheelchair (PWC) accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the requested items are covered when criteria in the 
Medicare Rules section are 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 power wheelchair (PWC) 
accessories. Our reviewer says that the member does not need these items. Our physician reviewer found the 
member does not have high risk for skin breakdown, edema, 90 degree flexion, and does not have power 
recline criteria in absence of ventilator or catheter and skin breakdown risk. 
 
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 power wheelchair (PWC) accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the power elevating leg rest/platform (E1012), and 
electronic connection between wheelchair controller and 2 or more power seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the services requested are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there are no red 
flags are noted thus the medical necessity of the right shoulder MRI without a 6-week trial of conservative 
management including PT has not been established in the records submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 99205. The Plan denied your request. The Plan says payment for 
code 99205 is bundled into payment for code 77263. 
 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 99205 
is a column II code to column I code 77263. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99205 billed for date of service March 1, 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 enrollee's husband is requesting reconsideration 
stating if his wife isn't placed into an inpatient rehabilitation facility this could shorten her life span. He is 
unable to assist her. The Plan denied your request. The Plan says The IRF services your appellant is requesting 
do not meet the requirements for approval. The records show the enrollee has muscle weakness and receiving 
antibiotic medicine for an infection in the blood. The enrollee may safely receive services in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee is medically stable and does not need a rehabilitation physicians close supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. No rehab nursing needs identified or documented. While the enrollee will benefit from physical 
therapy (PT) and occupational therapy (OT), her rehab needs can be safely met in an alternate and low intensity 
setting such as in a skilled nursing facility (SNF) setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
July 30, 2022, through August 2, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital admission 
was medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient 
psychiatric hospital admission was 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 pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital admission was not medically necessary. Our physician reviewer found that 
the enrollee was admitted for the acute inpatient psychiatric hospitalization on July 30, 2022 with 
Schizoaffective Disorder. Based upon the review of the records provided, it was not expected this enrollee 
would improve in a reasonable period of time as he did not have dangerousness to self or others. He had 
auditory no visual hallucinations, delusions and was not showing any behavioral issues. 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 as he did not have dangerousness to self or others, nor did he have perceptual 
disturbance including delusions. The health plans denial of inpatient psychiatric services appears appropriate. 
This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or 
others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not 
appear that the services were reasonably expected to improve the enrollees condition or were for the purpose 
of a diagnosis. Based upon the review of the records provided, the enrollee does not meet criteria for coverage 
of the acute inpatient mental health treatment provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from July 30, 2022, through August 2, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on August 11, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interfyl injection (Q4171). 
 
You asked the Plan to pre-approve Interfyl injection. You say that Interfyl is a 361 product. You say that the 
enrollee has tried and failed all available conservative care options. You say that the lack of long-term results 
supports their desire to proceed with this procedure. You also say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for Interfyl 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 Interfyl injection. Our reviewer says 
that the requested Interfyl injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate how many corticosteroid injections 
have been performed, if the enrollee has undergone physical therapy, immobilization, how many laser 
treatments they have undergone, and if they have utilized orthotic therapy. The reviewer found that additional 
research needs to be performed to determine its efficacy. The reviewer also found that it is unclear whether the 
Interfyl is equally as effective as surgical intervention. Therefore, the reviewer found that the requested Interfyl 
injection 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 Interfyl injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Interfyl injection (Q4171).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 23, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that data supports the use of Euflexxa. The Plan denied 
your request. The Plan says the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will 
approve Euflexxa. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. 
The records do not show that these drugs would likely be less effective and/or have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.