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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that the enrolleewould require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided on October 23, 
2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the documentation 
submitted did not sufficiently support the billed supply code. 
 
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 argues that the documentation submitted did not sufficiently support 
the billed supply code. However, the records contain an itemized packing slip dated September 23, 2022, with 
the same tracking number as the delivery ticket dated September 28, 2022. As such, the records support that the 
items at issue in this case were delivered. The billed code is supported. Therefore, we decided that the Plan has 
to pay for the electrical stimulator supplies (A4595) provided on October 23, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99283 and 28630 provided on October 20, 2022. 
 
You asked the Plan to pay for procedure codes 99283 and 28630. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. In this case, we find that the Plan has not provided enough evidence to deny 
payment for procedure codes 99283 and 28630 based on Medicare criteria. The Plan denies payment for these 
services based on requested additional medical records not received. The case file clearly contains medical 
records. The Plan's documented efforts to obtain additional records does not explain what additional records are 
needed and why the already provided medical records were inadequate. Therefore, we decided that the Plan has 
to pay for procedure codes 99283 and 28630 provided on October 20, 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 a MyoPro power arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro power arm brace. You say that this device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested device is not medically necessary as 
it is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro power arm brace. Our 
reviewer says that the requested MyoPro power arm brace is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based 
on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro 
is not the standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for the enrollee. There is insufficient evidence in the literature that this device will increase 
participation in bimanual activities. Therefore, the reviewer found that the requested orthosis 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 a MyoPro power arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro power arm brace (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on September 26, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport service was not medically necessary. 
Our physician reviewer found the enrollee who was transported non-emergently via ambulance from the 
hospital to a rehabilitation center following treatment for hip replacement surgery was not medically necessary. 
Vitals were stable. The enrollee was unable to tolerate seated position and was transported via stretcher. The 
enrollee did not require any treatment during transport.  
  
The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for a safe transport. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid endoskeletal knee-shin system (L5828), a 
dynamic response foot with multi-axial ankle (L5979), and additional prosthetic components (L5845, L5850, 
L5925). 
 
You asked the Plan to pre-approve a fluid endoskeletal knee-shin system, a dynamic response foot with multi-
axial ankle, and additional prosthetic components. You say that these items are medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
and a dynamic response foot with multi-axial ankle are covered for beneficiaries whose functional level is 3 or 
above. Components coded as L5845, L5850, and L5925 are additional features and/or functions that do not 
describe a complete endoskeletal knee-shin system and must be used in combination with a knee-shin system.  
 
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 fluid endoskeletal knee-shin system, a 
dynamic response foot with multi-axial ankle, and additional prosthetic components. Our reviewer says that the 
requested prosthetic components are not medically necessary. Our physician reviewer found the submitted 
records do not support that the enrollee is a K3 ambulator. The request exceeds the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a fluid endoskeletal knee-shin system, a dynamic response foot with multi-axial 
ankle, and additional prosthetic components have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a fluid endoskeletal knee-shin system (L5828), a dynamic response foot with multi-axial 
ankle (L5979), and additional prosthetic components (L5845, L5850, L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99220) provided on February 22, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was 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 99220 is Initial Hospital Care, requiring 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 the hospital care. Our reviewer says that the records do not 
support the code billed. Our reviewer found the records do not show medical decision making of a high 
complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99220) provided on February 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from March 26, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk and need physical therapy to 
increase your strength and possibly walk again. The Plan denied your request. The Plan says you no longer 
require skilled services on a daily inpatient basis. The Plan states the continuation of a skilled nursing facility is 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you have had functional/clinical status change; 
thus, skilled nursing/therapy would be medically appropriate. While hospitalized evaluating therapists 
recommended intermittent skilled therapy with home health, no recommendation for skilled nursing was given. 
There is no recommendation by provider or team for continued daily skilled services on an inpatient basis in a 
SNF. The continuation of SNF care is not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from March 26, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you on October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the services provided to you on October 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ClariFix procedure (Coblation-assisted turbinoplasty) 
(30999). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment 
of the enrollee's health problem. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has vasomotor rhinitis and chronic laryngitis. There is 
insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific 
conditions. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ClariFix procedure (Coblation-assisted turbinoplasty) (30999).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor 
(K0553) provided on November 23, 2022. 
 You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that 
the documentation supports the claim submitted. The Plan denied your request. The Plan says that the 
information on the proof of delivery does not match the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and Medicare rules. The record does contain a valid proof of delivery showing the correct 
date of service. Based on this information, we decided that Medicare rules for coverage of the supply allowance 
for therapeutic continuous glucose monitor have been met. Therefore, we decided that the Plan has to pay for 
the supply allowance for therapeutic continuous glucose monitor (K0553) provided on November 23, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 24 one-way transportation trips when each one-way trip does not exceed 30 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance rendered on November 5, 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. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 and half leg appliance rendered on November 5, 2021.
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. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
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 you do not require an acute rehabilitation hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including  
 either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You can receive 
further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three visits weekly to regain or maintain your functional status. You can receive further services at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.