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 enrollee is being discharged without regaining 
full strength and is a fall risk. The Plan denied your request. The Plan says the enrollee's records do not show 
the need for complex rehabilitation requiring frequent evaluation by a rehabilitation doctor. 
 
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 not a reasonable expectation that the 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 the power wheelchair itself and the other requested 
items/accessories (CPT code(s): K0835, E0955, E1002, E1020, E1028, E2361 and E2603). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for a Group 2 power wheelchair (PWC) with 
the requested power option(s)/feature(s). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found there is insufficient documentation that the enrollee in this case is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift or utilizes intermittent catheterization for 
bladder management and is unable to independently transfer from the wheelchair to bed, or a power seating 
system is needed to manage increased tone or spasticity. As these criteria are not met, the power seating 
component is denied as not reasonable and 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair itself and the other requested items/accessories (CPT code(s): K0835, 
E0955, E1002, E1020, E1028, E2361 and E2603).
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 is medically ready to 
transition to the LTACH in an effort to regain maximum prior level of functioning and a continued multi-
disciplinary approach to care. The Plan denied your request. The Plan says criteria for admission to the LTACH 
have not been met. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from January 3, 2022, through 
January 12, 2022. 
 
You asked the Plan to pay for the medical services. You say that records were already submitted, and the Plan 
should find them to support the billed services. The Plan denied your request. The Plan says no medical records 
were submitted with the appeal, and none were forwarded after requests. 
 
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 of the medical services have been met. 
The file does not include medical records despite attempts from the Plan to obtain them. Therefore, we decided 
that the Plan does not have to pay for the medical services provided from January 3, 2022, through January 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 14, 2022, billed with 
code 93313-59. 
 You asked the Plan to pay for the services as billed. You say that it is felt that this should be paid as billed. The 
Plan denied your request. The Plan says the use of modifier -59 is not appropriate to bypass the edit between 
these two codes. 
 
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 93313 is a column II code to column I code 00567; however, 93313 
was billed with a modifier.  
 
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 services as billed. Our reviewer says that the 
documentation does not support that the services described by code 93313 were separate and distinct from the 
anesthesia services. Our reviewer found in this case, the records do not include a diagnostic interpretation 
report of echocardiography written by the anesthesiologist. This is not shown to be separate from the anesthesia 
services rendered. 
 
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on April 14, 2022, billed with code 93313-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and drug testing to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and drug testing to be provided by an OON provider. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-
network providers available to you that can provide the services you are requesting. 
 
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 
office visits and drug testing to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and pulp vitality tests 
(D0460) provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were recommended. The Plan 
denied your request. The Plan says your benefit for the limited oral exam has already been exhausted. The pulp 
vitality tests are not covered under your benefits. 
 
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 limited oral exam was exhausted on date of service August 18, 2022. The pulp 
vitality tests are not covered under your benefits. Therefore, we decided that the Plan does not have to pay for 
the limited oral exam (D0140) and pulp vitality tests (D0460) provided on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested LDCT is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
LDCT. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee has signs and symptoms that can be attributed to lung cancer. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT code(s): 95907 and 95886) provided on 
June 23, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 95907 is nerve conduction studies; 1-2 studies and code 
95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with 
nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by 
three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 
 
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 services. Our reviewer found code 95907 - The 
documentation submitted was reviewed and does not meet criteria. The procedure report does not include 
documentation of nerve conduction studies; 1-2 studies. The documentation includes pedicle screw stimulation, which would not be reported as nerve conduction studies which measure amplitude latency/velocity. Therefore, 
this procedure cannot be verified. Code 95886 - The documentation submitted was reviewed and does not meet 
criteria. The procedure report does not include nerve conduction studies, as per CPT 95886 code description, 
"done with nerve conduction". Therefore, this procedure cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT code(s): 95907 and 95886) provided on June 23, 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 
you to receive the care needed to help you become more stable. 
 The Plan denied your request. The Plan says the services you need could be provided in another setting, such 
as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. There are no services available at the LTACH that you require 
that are not available at the health care setting being offered by the health plan. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary and cannot be met in a 
lower level of care setting. The Plan denied your request. The Plan says the enrollee can receive the services 
needed at an alternate level of care such as in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records show there are no complex or acute medical concerns that the complexity of the patient's documented nursing, medical and rehabilitation needs would not be expected to require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to return home. The Plan denied your request. The Plan says the enrollee's needs can be met in another setting, 
such as home health or with part time services in a long-term care facility. 
 
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 there are no identifiable skilled nursing service needs. The enrollee does not require 
skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting, skilled therapy service needs can be 
met in another 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 you disagree with the denial and think an IRF 
admission is necessary. The Plan denied your request. The Plan says you do not meet the medical necessity 
criteria for an inpatient rehabilitation facility (IRF) admission. 
 
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 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. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 expandable controller and harness upgrade with 
electronic connection. 

You asked the Plan to pre-approve 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 an expandable controller is used to control 
multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness is not needed to control 
the approved power switches. 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 an expandable 
controller and harness upgrade with electronic connection.
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 currently in the hospital and medically 
clear for discharge to an inpatient rehabilitation facility. The Plan denied your request. The Plan says the 
records do not show the enrollee's need for three hours of rehabilitation therapy per day. 
 
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 not a reasonable expectation that the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you live alone and are not able to care for yourself. 
You say that you need 24-hour care and cannot get in and out of your wheelchair alone. The Plan denied your 
request. The Plan says you do not meet medical necessity criteria for a SNF admission. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You are 
medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or 
near your baseline and 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.