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

 We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service (99053) and the emergency department visit (99285) provided on May 
26, 2021. 
 
You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility, in 
addition to basic service and emergency department visit. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
services billed. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
 
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 emergency department visit (99285). Our reviewer says 
that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
emergency department visit does not support 99285 level of service.  Per coding guidelines, this code required 
an expanded problem focused history, a comprehensive exam and moderate complexity medical decision 
making. 
 
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 emergency department visit (99285) have not been met. Additionally, CPT 
code 99053 has a status indicator of B meaning that payment for CPT code 99053 is always bundled into the 
payment for another service or procedure. Therefore, we decided that the Plan does not have to pay for the 
services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) and 
the emergency department visit (99285) provided on May 26, 2021.
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 enrollee cannot be adequately cared 
for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee does not need continued treatments that can only be given in the 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 physician 
reviewer found that the enrollee was admitted with acute encephalopathy and acute respiratory failure. The 
records indicate that the enrollee requires continued 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 he is not currently receiving but that would be available 
at the LTACH facility. 
 
 
 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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. While 
the enrollee may benefit from physical and occupational therapy, his rehabilitation needs can be addressed at a 
low intensity alternate setting such as in a skilled nursing facility. 
 
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 consultation with an endodontist. 
 
You asked the Plan to pre-approve endodontist consultation. You say that you are in pain and cannot eat, so 
you need to have this tooth removed. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because service by an endodontist is not covered by the Plan's dental 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, 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 a 
consultation with an endodontist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interfyl CMT. 
 
You asked the Plan to pre-approve the interfyl CMT. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the interfyl CMT. Our reviewer says 
that the drug is not medically necessary. Our physician reviewer found that the Food and Drug Administration 
has not stated that the requested drug is indicated for your condition and the Medicare approved drug 
compendia does not contain a supportive citation for the use or safety and efficacy of the requested drug in 
your clinical situation. 
 
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 interfyl CMT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the interfyl CMT.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not need daily skilled 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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There 
are no identifiable skilled nursing needs. Regarding rehabilitation services, the enrollee was at a standby assist 
to moderate assist level for functional mobility. She required varying assist with activities of daily living. There 
are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a 
daily basis. She does not meet severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with acute respiratory failure in the setting of Guillain-Barre syndrome exacerbation. 
She requires ongoing acute care services that are not denied. She continues to receive acute care services at the 
current hospital. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The LTACH services are not reasonable 
or medically 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 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for lumbar spine surgery. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While se has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 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 a tub stool (E0245). 
 
You asked the Plan to pre-approve a tub stool. You say that you are at risk of falling and you urgently need the 
tub stool. The Plan denied your request. The Plan says the tub stool is considered a convenience item and is not 
primarily medical in nature. The Plan also says this is not a covered item with Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tub stool (E0245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says no more than 
20 acupuncture treatments may be administered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  More than 20 acupuncture visits were requested. We looked at the file and Medicare rules. Your plan only 
covers up to 20 acupuncture visits per year. Based on this information, we decided that the rules for coverage 
of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional acupuncture visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an annual club membership provided on March 6, 2021. 
 
You asked the Plan to reimburse you for an annual club membership. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says club fees are not 
covered under the Plan's supplemental benefit. 
 
The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan 
including applicable conditions and limitations. The Plan offers reimbursement for certain services not covered 
by Original Medicare. The Plan's rules for coverage of the club fees have not been met because the Plan 
does not cover club fees under the supplemental benefit. Therefore, we decided that the Plan 
does not have to reimburse you for an annual club membership provided on March 6, 2021.
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 service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not medically necessary. 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 heavy-duty wheeled walker (E0149) and a walker seat 
attachment (E0156). 
 
You asked the Plan to pre-approve a heavy-duty wheeled walker and a walker seat attachment. You say that the 
current walker you have does not work for you. You also say that you are too large for the small walker, and 
you cannot keep pushing the tiny walker. You have to bend down far too low to reach the walker and it causes 
great pain in your back and arms. You feel that you can fall or injure yourself and you cannot sit in the walker 
as it is too small for you. The Plan denied your request. The Plan says you do not meet the established criteria 
for a heavy-duty walker with a seat. 
 
The Plan follows Medicare rules. Medicare rules say that a heavy-duty walker (E0148, E0149) is covered for 
beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds.  
 
The file shows that you do not weigh 300 pounds or more. The records show that you weigh 249 pounds. The 
LCD confirms that a heavy-duty walker is covered for a person who weighs more than 300 pounds. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty wheeled walker (E0149) and a walker seat attachment (E0156).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Pemetrexed. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the 
enrollee does not have an accepted medical indication for Keytruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested drugs. Our physician 
reviewer found that the enrollee has lung cancer with metastasis to the breast and brain. The requested drug 
regimen is not FDA-approved for the enrollee's diagnosis without ALK and EGFR testing. The requested use is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. The use is not listed as not indicated, not supported or not recommended in any of the 
compendia. The documentation does not support that the requested drug is safe and effective and otherwise 
reasonable and necessary for this enrollee. 
 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 requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Keytruda, Carboplatin, and Pemetrexed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aid services (V5260, V5264, V5011, V5241). 
 
You asked the Plan to pre-approve hearing aid services. You say that these services are necessary. The Plan 
denied your request. The Plan says hearing aids and related services are not covered by Medicare or by the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though hearing aid services may be appropriate in this case, neither Medicare nor the Plan covers or pays for 
these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aid 
services (V5260, V5264, V5011, V5241).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Repatha Sure. 
 
You asked the Plan to pre-approve the Repatha Sure. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says this is considered a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Repatha Sure.  
 
Benefits for the Repatha Sure may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says SNF services are 
not medically necessary. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found based on the documentation 
provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care 
(ex. home, assisted living, long term 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.