Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is medically necessary care that should 
be reimbursed. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2022, to September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation services coded G0281 provided 
October 25, 2021, through October 27, 2021. 
 
You asked the Plan to pay for the electric stimulation services coded G0281. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is a more 
appropriate code to describe the services provided. 
 
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 G0281 is electrical stimulation, (unattended), to one or 
more areas, for chronic stage iii and stage iv pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis 
ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy 
plan of care. 
 
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 electric stimulation services coded G0281. Our reviewer 
says that the documentation does not support payment for the services as billed. Our reviewer found medical 
records do not support the use of procedure code G0281 as the stimulation was not done for ulcers. There is a 
more appropriate code that can be used that should be billed. 
 
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 electric stimulation services coded G0281 have not been met. Therefore, we 
decided that the Plan does not have to pay for the electric stimulation services coded G0281 provided October 
25, 2021, through October 27, 2021.
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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the member does not meet the Medicare 
criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 pay for continued treatment with tumor treatment field therapy 
(TTFT) on April 15, 2022. 
 
You asked the Plan to pay for continued treatment with tumor treatment field therapy (TTFT). You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this is 
not covered for treatment of recurrent glioblastoma. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT for recurrent glioblastoma is not covered. 
 
The enrollee's diagnosis of glioblastoma is recurrent as it was diagnosed in 2017. Based on this information, we 
decided that Medicare rules for coverage of the treatment have not been met. Therefore, we decided that the 
Plan does not have to pay for continued treatment with tumor treatment field therapy (TTFT) on April 15, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are at greater risk of infection and further 
complications if you stay where you are. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you are medically improving with pulmonary debility and do not need physical 
medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you may benefit from 
physical therapy and occupational therapy, your rehabilitation needs can be safely met in an alternate and low 
intensity setting such as in an SNF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support a need for cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in your 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be transferred to receive the care and 
assistance from the provider as you had a psychopath condition and are not in good health. The Plan denied 
your request. The Plan says you do not meet criteria for admission to the IRF. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for sepsis, a lower leg infection, and a below the knee amputation. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for 
physical therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided a in a different level of care. 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. 
 
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: 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 the enrollee is unable to care for themselves doing 
daily activities such as preparing meals or getting dressed. You say that the enrollee is at risk of infection if not 
cared properly also being a big fall risk since they have no one to assist at home. The Plan denied your request. 
The Plan says a SNF admission is not medically necessary, and the enrollee needs can be met at a lower level 
of care.  
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 this admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
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 specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new eye examination and glasses. 
 
You asked the Plan to pre-approve a new eye examination and glasses. You say that you had an eye 
examination done virtually and then waited over 30 days to find a pair of glassed you like. You also say that 
the prescription is blurry, but when you called the office, they said they will not help you because it is past the 
30 day guarantee date. The Plan denied your request. The Plan says your benefit is exhausted. 
 
  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 one routine eye examination per calendar year, and the choice of one pair or 
eyeglasses or contact lenses per year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye examination per 
calendar year, and the choice of one pair or eyeglasses or contact lenses per year. The record shows this benefit 
was exhausted on August 16, 2022. The record also shows that you waited past the 30 day guarantee date to 
contact the provider. Based on this information, we decided that the Plan's rules for coverage of a new eye 
examination and glasses have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
new eye examination and glasses.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital stay for an electroencephalogram with 
video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with 
continuous, real-time monitoring and maintenance (95716). 
 
You asked the Plan to pre-approve inpatient hospital stay for an electroencephalogram with video (VEEG), 
review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, 
real-time monitoring and maintenance (95716). You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee could receive the care needed in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital stay for an 
electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each 
increment of 12-26 hours; with continuous, real-time monitoring and maintenance (95716). Our reviewer says 
that the documentation does not support that the criteria for inpatient stay are met in this case. Our physician 
reviewer found the record provided does not indicate that the treating physician has a reasonable expectation of 
a length of stay spanning two or more midnights, taking into account complex medical factors. Our physician 
reviewer also found that the initial day may be spend in observation until it is clearly expected that a second 
midnight would be required, at which time the physician may order inpatient admission. Our physician 
reviewer also found that the enrollee has a known diagnosis of seizure therefore ambulatory monitoring is 
excluded by rule and an inpatient stay is not required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital stay for an electroencephalogram with video (VEEG), review 
of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, real-time 
monitoring and maintenance (95716) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve inpatient hospital stay for an electroencephalogram with video (VEEG), review of data, technical 
description by EEG technologist, each increment of 12-26 hours; with continuous, real-time monitoring and 
maintenance (95716).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you have wounds on both your legs. You 
say that you need assistance changing your bandages. You say that you cannot walk without falling. You also 
say that you desperately need assistance. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve skilled nursing visits (G0299).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3. 
 
You asked the Plan to pre-approve Visco-3. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Durolane, Gelsyn-3 and Synvisc or Synvisc-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Visco-3. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visco-3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTC services. 
 
You asked the Plan to pre-approve the LTC services. You say that the admission is based on medical necessity. 
The Plan denied your request. The Plan says Medicare does not cover custodial care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term acute care services have not been met. Specifically, we find that the services at issue 
in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
long term care (LTC) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation with bone or bone substitutes via a 
lateral open approach (code D7951), full-size implants (code D6010), guided tissue regeneration (code D4266) 
and surgical placement of the implant post (code D6011). 
 
You asked the Plan to pre-approve sinus augmentation with bone or bone substitutes via a lateral open 
approach (code D7951), full-size implants (code D6010), guided tissue regeneration (code D4266) and surgical 
placement of the implant post (code D6011). The Plan denied your request.  
 
 The Plan says Plans enhanced dental benefit limits have been met for calendar year 2022 for full-size implants 
(code D6010). The Plan also says that sinus augmentation with bone or bone substitutes via a lateral open 
approach (code D7951), guided tissue regeneration (code D4266) and surgical placement of the implant post 
(code D6011) are not covered under the Plans dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve sinus 
augmentation with bone or bone substitutes via a lateral open approach (code D7951), full-size implants 
(code D6010), guided tissue regeneration (code D4266) and surgical placement of the implant post  
(code D6011).