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

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. 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 follows Medicare rules. Medicare rules say that PTA is covered when specific criteria are met. 
 
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 revascularization services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not support the medical necessity of the treatments in question. On multiple visits there is documentation 
that the enrollee denies claudication and denies foot complaints. There is no description of the nature of the 
enrollees symptoms. No pulse examination is provided.  There is no documentation that the enrollee has any 
signs of limb threat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service February 7, 
2022.  You asked the Plan to pay for procedure code 20930. You say that the operative report should be reviewed, and 
the claim reprocessed for payment. The Plan denied your request. The Plan says procedure code 20930 is 
considered bundled and not separately payable. 
 
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) and the 
extractions (D7210 x2) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation (D0150) and the extractions (D7210 x2). 
You say that your teeth are hurting, and the teeth are broken. The Plan denied your request. The Plan says the 
services are not covered 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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve the comprehensive oral evaluation (D0150) and the extractions (D7210 x2) to be 
provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee could do better in rehabilitation. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable, and 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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sotalol AF. 
 
You asked the Plan to pre-approve Sotalol AF. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Sotalol AF.  
 
Benefits for Sotalol AF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is non-coverable.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record does not support that the enrollee is at high risk for skin breakdown. The enrollee does not use intermittent catheterization. The enrollee has adequate strength to manage the standard switches for multiple power drives. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
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 medical center is recommending that you go to 
an acute rehabilitation facility. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 were admitted for weakness, a fall, and COVID infection. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says based on Medicare 
guidelines the skilled nursing facility services you are requesting do not meet the requirements for approval. 
 
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 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. Our 
reviewer also found the enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kovaltry. 
 
You asked the Plan to pre-approve Kovaltry. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Kovaltry.  
 
Benefits for Kovaltry 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clamp handles and a smartdrive push tracker. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The items are for convenience purposes and not covered. Therefore, we decided that the Plan does not have to pre-approve clamp 
handles and a smartdrive push tracker.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 14, 2022, billed 
with code 61624. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that the claim is correctly coded for 
the services rendered. The Plan denied your request. The Plan says one denied code was approved on appeal; 
however, code 61624 remains unsupported.  
 
 
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 61624 is Transcatheter permanent occlusion or 
embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), 
percutaneous, any method; central nervous system (intracranial, spinal cord). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services as billed. Our reviewer says that the 
documentation does not support the use of the billed code. Our reviewer found the operative report describes an 
embolectomy/thrombectomy, and this service would not be reported with this procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on February 14, 2022, billed with code 61624.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is expected to return to his prior level of 
functioning with rehabilitation. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a transient ischemic attack. The enrollee's medical problems are stable, and 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. 
 
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 enrollee's neurosurgery team and therapy team 
have both recommended acute inpatient rehabilitation. You say that the enrollee is capable and willing to 
participate in three hours of therapy per day and eager to return to her independent life. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 was admitted for lumbar spine surgery. The enrollee's medical problems 
are stable, and 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. 
 
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 ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
bilevel positive airway pressure (BiPAP) was ordered. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement, primary and permanent teeth 
(D3221) provided on August 3, 2022. 
 
You asked the Plan to pay for the pulpal debridement. You say that this was a necessary service you feel should 
be covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulpal 
debridement, primary and permanent teeth (D3221) provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
August 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by the enrollees 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. 
 
The record shows you received the requested 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 pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210) provided on August 15, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
dental services to be provided by an out-of-network (OON) provider.