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

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
February 13, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
February 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echo exam provided on December 27, 
2021. 
 
You asked the Plan to waive the copayment for echo exam. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for echo exam. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. 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 waive the 
copayment for echo exam provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parts for wheelchair repairs coded as K0077, K0108, 
K0070, E2206. 
 
You asked the Plan to pre-approve parts for wheelchair repairs. You say that you've had the chair for 2 years 
and the brakes are shot, bearings are shot, and the wheelchair is just busted. The Plan denied your request. The 
Plan says there are a lot of line items in the detailed product description that have no justification. 
 
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 parts for wheelchair repairs. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with a medical history including a previous spinal cord injury resulting in paraplegia who uses a manual wheelchair for mobility-related self-care tasks. The documentation 
indicates the chair is 2 years old and the enrollee intends to repair the chair. The order form has multiple line 
items without a justification. In this case, the documentation does not include detailed justification for each part 
that is being requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parts for wheelchair repairs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parts for wheelchair repairs coded as K0077, K0108, K0070, E2206.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve presbyopia correcting function of intraocular lens 
(V2788) and unlisted procedure, ORA system vision testing (66999). 
 
You asked the Plan to pre-approve vision services. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says you are having placement of a premium lens and 
specialized vision testing using the ORA System. The Plan also says they are unable to approve the request for 
coverage that exceeds what Original Medicare allows. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve presbyopia correcting 
function of intraocular lens (V2788) and unlisted procedure, ORA system vision testing (66999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's admission to an IRF is the best course 
of action. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee's needs can be met at 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 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 rib fractures and a stroke. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this procedure is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy. 
 
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 Intracept procedure have not been met.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629).
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 a LTACH setting is necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 they are currently receiving care. All medically necessary care is being provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823, E2365, E0973, E1028) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair. You say that this power wheelchair is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair (K0823, E2365, E0973, E1028) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lipectomy procedure (15877). 
 
You asked the Plan to pre-approve a lipectomy. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lipectomy. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee previously underwent abdominal lipectomy. The available medical records do not 
indicate the presence of intertrigo refractory to treatment, chronic pain or functional impairment. 
 
 
  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 lipectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lipectomy procedure (15877).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and reasonable. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 18, 2022.
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 documentation shows that the enrollee has complex functional impairments and 
active medical comorbidities, however the evaluating therapists recommend therapy in a less intense setting 
due to patient tolerability thus the enrollee would not be expected to tolerate 15 hours of therapy per week. 
 
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 heavy-duty walker with four wheels and seat attachment. 
 
You asked the Plan to pay for heavy-duty walker with four wheels and seat attachment. You say that this item 
will help you gain your freedom from the wheelchair and wheelchair van. The Plan denied your request. The 
Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. Review of the file does not support that you weigh at least 300 
pounds. Based on this information, we decided that Medicare rules for coverage of heavy-duty walker with 
four wheels and seat attachment have not been met. Therefore, we decided that the Plan does not have to pay 
for heavy-duty walker with four wheels and seat attachment.
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 documentation shows that the enrollee has functional impairments, but no complex 
functional deficits are specified thus would not be expected to require intense therapy or interdisciplinary team 
management of rehabilitation in an IRF setting. Clinical documentation does not show any active medical 
comorbidities thus the enrollee would not be expected to require continued inpatient hospitalization during 
rehabilitation. The complexity of the enrollee's nursing, medical and rehabilitation documented needs would 
not 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 continued skilled nursing facility care. 
 
You asked the Plan to pre-approve continued skilled nursing facility care. You say that an extended stay at the 
skilled nursing facility is medically necessary. The Plan denied your request. The Plan says you have used your 
allotted skilled nursing facility days that are covered under your plan during your current benefit period. 
 
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 April 4, 2022, through 
October 29, 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 continued skilled nursing facility care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement group 3 power wheelchair and 
accessories (K0861, E0953, E0954, E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2361, E2377, 
E2607, E2620). 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the enrollee currently has a power wheelchair that 
is less than 5 years old. Per Medicare rules, replacement due to wear is not covered during the reasonable 
useful lifetime of the equipment (less than 5 years). 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee currently has a power wheelchair. A power wheelchair serves the same purpose 
as a replacement power wheelchair and accessories. Therefore, we decided that the Plan does not have to pre-
approve a replacement group 3 power wheelchair and accessories (K0861, E0953, E0954, E0955, E0956, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone graft replacement (D7953) Tooth #30. 
 
You asked the Plan to pay for dental services. You say that the bone graft should be a covered benefit under the 
Plan. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Bone graft replacement 
(D7953) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Bone graft replacement 
(D7953) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for bone graft replacement (D7953) Tooth #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-stabilization of care services provided from July 17, 
2022, through July 19, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee was admitted to the hospital from 
the emergency room without the required authorization. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 these services. Our reviewer says that the 
post stabilization of care services provided were not medically necessary. Our physician reviewer found that 
the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport 
with monitoring to a Plan facility for admission after the emergency room evaluation on July 17, 2022. There 
was no documentation provided indicating the medical necessity for post-stabilization of care services at the  
non-Plan facility. The enrollee did not require intensive care unit level of care services. She did not have 
recurrent chest pain or refractory congestive heart failure. The review has determined that the treating physician 
did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer 
on any dates of service. 
 
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 pay for the post-stabilization of care services provided from July 17, 2022, through July 19, 2022.