Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
October 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service was inappropriate for this procedure. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
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 says that the services at issue in 
this case were not supported by the medical records.  Our reviewer found that in this case, this procedure is a technical component only, as the independent trained 
observer services would be covered by the facility. Therefore, this procedure was reported incorrectly. 
 
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 moderate sedation services provided to the enrollee on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve presbyopia correcting function of an intraocular lens 
(V2788). 
 
You asked the Plan to pre-approve presbyopia correcting function of an intraocular lens. You say that your 
provider has recommended a Torie Lens be placed during outpatient surgery to help with astigmatism and 
vision complications after a recent stroke. The Plan denied your request. The Plan says the requested service is 
not covered by Medicare or the plan. 
 
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 an intraocular lens (V2788).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a private duty/independent nursing service. 
 
You asked the Plan to pre-approve a private duty/independent nursing service. You say that the enrollee wants 
to continue care with a private duty nurse. The appellant says that the enrollee does not want home health 
services. The appellant says that the enrollee has progressive back pain and neck pain and is unable to perform 
activities of daily living. The Plan denied your request. The Plan says the requested services are non-covered 
by Medicare and under this contract. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the services of a private-duty nurse or other 
private-duty attendant are not covered. Therefore, we decided that the Plan does not have to pre-approve a 
private duty/independent nursing service.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says that the patient does not meet criteria for facet joint 
injections. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the patient 
meets the criteria listed in the rules section of this decision letter. 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 facet joint injections. Our reviewer says that the requested facet joint injections are 
medically necessary. Our physician reviewer found this patient has chronic axial low back pain. The request 
was for a diagnostic facet block but by mistake the biologic box was checked by the physician. There is a 
handwritten progress note correction of this error.  A diagnostic facet injection is appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve facet joint injections.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction. 
 
You asked the Plan to pre-approve the dental services. You say that your teeth are spoiled, and that you want 
them out so you can have dentures. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an 
extraction.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 13, 
2022. 
 
You asked the Plan to pay for the services. You say that this was a medically necessary procedure. The Plan 
denied your request. The Plan says Medicare says non-urgent services should be from network providers who 
are contracted with the health plan and listed in the Provider Directory 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on 
January 13, 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 does not meet 
criteria. 
 
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 your medical condition appears stable on outpatient medications with no issues that 
appear to require a physicians evaluation three or more times per week. You will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to your reported level of weakness and fatigue with therapy. Records do not clarify 
that treatment at the skilled nursing facility level is not appropriate in this case. 
 
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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for IRG 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 you are medically stable and do not need aphysician's supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehab nursing needs identified or documented. At the current functional level, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. IRF admission is not medically necessary based lack of medical 
complexity and acute rehab nursing need and high functional level. While you may benefit from continued 
therapy, your rehab needs can be safely provided in a lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gurney van transport you received on March 9, 2021. 
 
You asked the Plan to pay for the gurney van transport. You say that you did not have anyone to assist you to 
rehab privately and you needed assistance. The Plan denied your request. The Plan says transport by gurney 
van is not covered.  The Plan also says that even if this had been a coverable service, your copayment for 
ambulance transport is $200 per trip, and the cost of this service was less than this amount.  So, if this was a 
covered transport, you would still be responsible for the full cost because it is less than the applicable 
copayment. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for gurney van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for gurney van transport you received on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory services 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 the enrollee that can provide the laboratory services being requested. 
 
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 
laboratory services to be provided by an out-of-network (OON) provider.
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 is medically necessary. The Plan denied your 
request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided 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 that the documentation does not support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. The complexity of the enrollee's 
nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. There is no reasonable expectation that the enrollee would be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in the 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: 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 does not meet 
criteria. 
 
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 your medical condition appears to be stable on outpatient medications with no issues 
that appear to require a physicians evaluation three or more times per week. You do not require or have the 
endurance to participate with the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Records do not clarify that treatment at the skilled nursing facility level is not appropriate 
in this case. 
 
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 power operated vehicle, group 1 heavy duty, patient 
weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the requested POV is medically 
necessary. The Plan denied your request. The Plan says medical records received do not support that the 
enrollee met the guidelines for this device. 
 
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 a power operated vehicle. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has a mobility 
limitation, but the documentation is not clear that the enrollee is unable to perform MRADLs in the home. The 
documentation is not specific that the mobility limitation cannot be effectively overcome with a manual 
wheelchair. The documentation is not clear that the home is appropriate for a power operated vehicle as there 
are no objective measurements of the home indicating that the enrollee's home provides adequate access 
between rooms, maneuvering space, and surfaces for use of the mobility device that is being requested. 
Without evidence that the power operated vehicle will provide adequate space in the home, it is not clear that 
the requested mobility device will significantly improve participation in MRADLs in the home. The 
documentation is not clear that the enrollee can safely transfer to and from the power operated vehicle. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 
450 pounds (K0801).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prevymis. 
 
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 self-administered drugs are not covered. 
 
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 Prevymis.  
 
Benefits for these services 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: 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 is medically necessary. The Plan denied your 
request. The Plan says you do not meet the Medicare criteria for admission to an 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 that based on the medical records provided, the complexity of your nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions appear stable on outpatient medications with no issues that appear 
to require a physicians evaluation three or more times per week. The records do not clarify why an intensive 
rehabilitation program would be needed. There is no evidence that therapy at a lower level of care, such as in a 
skilled nursing facility, is not appropriate. 
 
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 core buildup, including any pins when required. 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat very well and have 
pain. The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has 
exceeded limits set in the subscriber agreement. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2018. 
Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins when 
required.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leadless pacemaker insertion. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the pacemaker for chronic 
atrial fibrillation and bradycardia. The Plan denied your request. The Plan says the criteria for coverage are not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered for beneficiaries 
enrolled in an FDA-approved approved study. 
 
We looked at the file and Medicare rules. The file shows that the services are not being requested as part of an 
FDA-approved study. 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 leadless pacemaker 
insertion.