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

 
We decided that the Plan does not have to pre-approve the pain management office visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pain management office visit. You say that this provider is close to your 
home. The Plan denied your request. The Plan says the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available within five miles who can provide the pain management office visit. We found no exception that 
would require the Plan to pre-approve the pain management office visit. The records provided for review do 
not show that pain management office visit is urgent or emergent. Therefore, we decided that the Plan does not 
have to pre-approve the pain management office visit to be provided by an out-of-network (OON) provider.
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 is being discharged and they are not 
ready to go home. The Plan denied your request. The Plan says the enrollee does not require an intensive, 
complex, multidisciplinary approach to daily therapy. Records do not support the need for an intensive 
rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care such as at a skilled 
nursing facility, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for a femur fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does 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 this enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iPad or tablet. 
 
You asked the Plan to pre-approve an iPad or tablet. You say that you cannot go to the provider's office for 
visits and you are no longer able to conduct telephone visits with your providers. The Plan denied your request. 
The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an iPad or tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis. 
 
You asked the Plan to pre-approve a knee orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered when the enrollee 
has had a recent knee injury, or surgery, or evidence of instability. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee has had a recent 
knee injury, or surgery, or evidence of instability. Based on this information, we decided that Medicare rules 
for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 27, 2021, through 
February 2, 2021, at DRG 853. 
 
You asked the Plan to pay for inpatient services at DRG 853. You say that pneumonia was documented, 
monitored, and treated throughout the encounter and meets criteria to be assigned as a secondary diagnosis. 
You say that you disagree with the change and DRG 853 should be reconsidered. The Plan denied your request. 
The Plan says diagnosis code J18.9 is not supported which results in a change from DRG 853 to DRG 854. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J18.9, defined as 
pneumonia, unspecified. 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 inpatient services 
at DRG 853. Our reviewer says that the documentation does not support secondary diagnosis code J18.9. Our 
physician reviewer found while there were questionable signs of right lower lobe pneumonia on the initial chest 
x-ray, the follow-up chest x-ray showed no evidence of pneumonia. The progress notes further indicated that 
the enrollee may have been experiencing acute pulmonary edema secondary to platelets. The diagnosis of 
pneumonia was noted to be ruled out at that point.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from January 27, 2021, through February 2, 2021, at DRG 853.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter rack for the car. 
 
You asked the Plan to pre-approve the requested services. You say that you will be too weak to breakdown or 
lift the scooter. The Plan denied your request. The Plan says changes to property are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Although this 
item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve a scooter rack for the car.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear wax removal (69210) provided on November 10, 
2021. 
 
You asked the Plan to pay for the ear wax removal (69210). You say that the physician provided medically 
necessary services that met recognized standards of healthcare and the claim should be processed for payment. 
The Plan denied your request. The Plan says medical records were not received to determine if payment should 
be made. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage have been met. Specifically, medical 
records were not received to support the service billed. Therefore, we decided that the Plan does not have to 
pay for the ear wax removal (69210) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion consultation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the second opinion consultation. You say that you are requesting a second 
opinion because you are not happy with the results given to you.  The Plan denied your request. The Plan says 
the provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the second opinion consultation. We found no exception that would require the Plan 
to pre-approve the second opinion consultation. The records provided for review do not show that the second 
opinion consultation is urgent or emergent.  
 
 Therefore, we decided that the Plan does not have to pre-approve the second opinion consultation to be 
provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the urology procedures to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the urology procedures. You say that this is a continuation of treatment that 
was provided during an emergency room visit by the same physician. You say you cannot wait to have the 
procedure done when you get home. The Plan denied your request. The Plan says the provider is out-of-
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the urology procedures. We found no exception that would require the Plan to pre-
approve the urology procedures. The record shows you were seen in the emergency room on June 13, 2022, 
and the urology services with the out-of-network provider were scheduled for August 1, 2022.  This is considered foreseen care and is no longer considered a follow-up. Therefore, we decided that the Plan 
does not have to pre-approve the urology procedures to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has edema without 
improvement from conservative measures. The Plan denied your request. The Plan says the enrollee does not 
have truncal edema. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The records show that the enrollee has edema in the lower 
extremities. The medical records do not show that the enrollee has lymphedema that extends into the chest, 
trunk, and/or abdomen.  Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an advanced pneumatic compression 
device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says skilled 
nursing facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 9, 2022, to 
August 9, 2022. The Plan has covered 100 days of SNF care. 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of anesthetic and/or steroid drug into upper or 
middle spine nerve root using imaging guidance under conscious sedation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve injection of anesthetic and/or steroid drug into upper or middle spine nerve 
root using imaging guidance under conscious sedation. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit and can be 
provided by a network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The rules also say 
that sedation is only covered when the documentation clearly establishes the need for such sedation in the 
specific enrollee. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. In addition, the requested sedation services are not covered 
because the documentation does not clearly establish the need for such sedation. Therefore, we decided that the 
Plan does not have to pre-approve injection of anesthetic and/or steroid drug into upper or middle spine nerve 
root using imaging guidance under conscious sedation to be provided by an out-of-network (OON) provider.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission 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 at no point in the record does the enrollee appear to have intensive rehabilitation 
needs. On June 15, 2022, she was walking at a community level and was at a level of function which routinely improves with repetitive exercise with support from a non-skilled person. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revision of total knee arthroplasty (27487) provided on 
September 21, 2021. 
 
You asked the Plan to pay for revision of total knee arthroplasty (27487). You say that this surgery allows for 
surgical assistants and payment restrictions do not apply. The Plan denied your request. The Plan says the 
modifier reported is not consistent with the diagnosis codes reported. 
 
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 27487 is revision of total knee arthroplasty, with or 
without allograft; femoral and entire tibial component. 
  We find that CPT code 27487 is not supported in the medical record. Specifically, the diagnosis code billed 
indicates encounter for right knee joint, but surgery was performed on the left knee. Based on this information, 
we decided that Medicare rules for coverage of revision of total knee arthroplasty (27487) have not been met. 
Therefore, we decided that the Plan does not have to pay for revision of total knee arthroplasty (27487) 
provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22612) and posterior segmentation (22842) 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not have the symptoms for these services. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. Additionally, the diagnostic imaging does not corroborate instability at the 
requested surgical levels. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these services. 
 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 pre-approve arthrodesis (22612) and posterior segmentation (22842) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of metastatic squamous cell carcinoma of the penis.  The record 
indicates that other treatments are not feasible due to frailty.  The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The National Comprehensive Cancer Network 
(NCCN) states that the requested drug may considered as a single agent treatment (preferred) for regional 
recurrence or distant metastatic disease if curative radiation therapy or curative surgery are not feasible. 
Therefore, the enrollee does not meet criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adaptive eating utensils. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested utensils are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The requested 
services would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does 
not have to pre-approve adaptive eating utensils.