Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 29581. You say that the claim should be reconsidered. The Plan 
denied your request. The Plan says payment for code 29581 is bundled into payment for code 11042. 
 
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 29581 
is a column II code to column I code 11042. 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 29581 billed for date of service June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the proper level of care. The Plan denied your request. The Plan says the enrollee can 
safely receive the care needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair and bathtub lift. 
 
You asked the Plan to pre-approve a bath/shower chair and bathtub lift. You say that the enrollee needs these 
items to assist with tub transfers. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that shower chairs and bathtub lifts are not covered 
because they are not primarily medical in nature.  
 
While a shower chair and bathtub lift may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair 
and bathtub lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210) provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 2, 2021. Therefore, 
we decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210) provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the needed results cannot be replicated with a 
positive airway pressure (PAP) device. The Plan denied your request. The Plan says a ventilator is not covered 
by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy  regardless of the underlying medical condition  shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's care. The Plan denied your request. The Plan says the enrollee's ongoing needs for skilled 
therapy, respiratory therapy, and skilled nursing may be completed in a lower level of care facility such as an 
inpatient rehabilitation facility or even a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH level of care. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and you can safely 
receive the care in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The health plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH level of care. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee's needs can be met in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized knee and advanced foot. 
 
You asked the Plan to pre-approve a computerized knee and advanced foot. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that advanced knees are covered for enrollees who are K3 
ambulators. 
 
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 computerized knee and advanced 
foot. Our reviewer says that the documentation does not support that the requested device is medically 
reasonable or necessary. Our physician reviewer found the enrollee has an amputation below knee on the right 
and a recent amputation on the left above the knee. The documentation does not support that the enrollee is a 
K3 ambulator. Therefore, the enrollee does not meet criteria for the requested advanced knee/foot. 
 
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 computerized knee and advanced foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized knee and advanced foot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebral axial decompression to be performed by a 
chiropractor. 
 
You asked the Plan to pre-approve vertebral axial decompression. You say that you would like this procedure 
instead of surgeries that have been proven not to work. The Plan denied your request. The Plan says this service 
is 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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve vertebral axial decompression to be performed by a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the single vision lenses provided on April 18, 
2022. 
 
You asked the Plan to pay for the frames and the single vision lenses. You say that the enrollee resides at a 
nursing facility and does not have a say who the facility chooses as the treating provider. The Plan denied your 
request. The Plan says the service was not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the frames and the single vision lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for the frames and the single vision lenses 
provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the Plan says 
there is no evidence that you are at high risk for an unplanned hospitalization in the next 60 days or that you 
have had 2 or more inpatient hospitalizations or 3 or more visits to the emergency room in the last 60 days. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 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 of SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code 22612. 
 
You asked the Plan to pre-approve procedure code 22612. You say that the services are necessary. The Plan 
denied your request. The Plan says payment for code 22612 is bundled into payment for code 22633. 
 
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 22612 
is a column II code to column I code 22633. 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 pre-approve procedure code 22612.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #4 provided on May 26, 
2022. You asked the Plan to pay more for the dental service. You say that you feel the dental services should be 
covered because the website showed the provider as an in-network provider. The Plan denied your request. The 
Plan says you are responsible for the difference in allowed amount and the proper cost share was applied. 
 
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. 
 
You have been asked to pay a 50% coinsurance and to pay the difference between the allowed amount of the 
less expensive alternate procedure. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a crown (D2740) for 
tooth #4 provided on May 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 76937 billed for date of service October 2, 
2022. 
 
You asked the Plan to pay for procedure code(s) 76937. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 76937. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 76937. Based on this information, 
we decided that Medicare rules for coverage of procedure code 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 76937 billed for date of service October 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade, harness upgrade, 
color 3.5 touch screen remote, power seat elevation system, back spreader bar, electronic connection between 
wheelchair controller and two or more power seating system motors, and center mount power elevating leg 
rest/platform. 
 
You asked the Plan to pre-approve an expandable controller upgrade, harness upgrade, color 3.5 touch screen 
remote, power seat elevation system, back spreader bar, electronic connection between wheelchair controller 
and two or more power seating system motors, and center mount power elevating leg rest/platform. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. Power seat elevation systems are not covered. 
 
We looked at the file and Medicare rules. The requested upgraded electronics (expandable controller, harness, 
and electronic connector to 2 power options) are necessary when there is a medical need to control power 
options through the joystick. The documentation does not support a medical need to control the power options 
through the joystick. The power options can be controlled using their own switches. The requested power seat 
elevation system is specifically not covered. The documentation does not support that the power leg lifts are 
medically needed. The touch screen is already included with the requested controller. The back hardware is 
already included with the requested cushion. These items cannot be requested separately.  
 
Based on this information, we decided that Medicare rules for coverage of an expandable controller upgrade, 
harness upgrade, color 3.5 touch screen remote, power seat elevation system, back spreader bar, electronic 
connection between wheelchair controller and two or more power seating system motors, and center mount 
power elevating leg rest/platform have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller upgrade, harness upgrade, color 3.5 touch screen remote, power seat 
elevation system, back spreader bar, electronic connection between wheelchair controller and two or more 
power seating system motors, and center mount power elevating leg rest/platform.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 you are medically stable and do not need physician's supervision 3 times a week in an 
IRF. There are no acute rehabilitation nursing needs identified or documented. At the current level of function, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with a multidisciplinary approach in an IRF. While you may benefit from continued physical therapy, and 
occupational therapy, your rehabilitation needs can be safely provided in a lower intensity and alternate 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the occupational therapy services. You say that the enrollee had surgery on 
February 6, 2023, and needs a certified hand therapist to regain motion. The Plan denied your request. The Plan 
says there is an in-network provider in the enrollees area, and the services requested are not urgent or 
emergent. The Plan also says it is not medically necessary for the enrollee to go to an OON therapist at this 
time. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
occupational therapy services to be provided by an out-of-network (OON) provider.