Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged and 
intensive skilled services that are not available at a lower level of care. The Plan denied your request. The Plan 
says based on Medicare guidelines the long term acute care hospital services you are requesting do not meet the 
requirements for approval. 
 
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 was admitted with dehydration and infected sacral pressure ulcer. The 
record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. The 
medical record does not indicate that the enrollee requires services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; electrical 
stimulation (manual), each 15 minutes (97032). 
 
You asked the Plan to pre-approve electrical stimulation. 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 nerve blockade and/or electrical stimulation are non-
covered for the treatment of metabolic peripheral neuropathy. 
 
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 electrical stimulation. Our reviewer says that the services are not medically necessary. Our physician reviewer found this is an investigational 
technique and therefore, the request is deemed not medically reasonable and 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 electrical stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve application of a modality to 1 or more areas; electrical stimulation (manual), each 
15 minutes (97032).
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 for the enrollee and are not 
able to be met in lower level of care. The Plan denied your request. The Plan says the services the enrollee 
needs can be provided safely in another setting such as a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 50-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you have many health 
appointments including dialysis coming up that you need transportation for. The Plan denied your request. The 
Plan says you have exhausted your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
50-trip limit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Memantine Titration Pack. 
 
You asked the Plan to pre-approve Memantine Titration Pack. You say that the records provided support the 
need for the requested drug. The Plan denied your request. The Plan says the requested medication does not fall 
under Part B coverage. The Plan says that they do not administer the enrollee's pharmacy benefits. 
 
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 Memantine Titration Pack.  
 
Benefits for Memantine Titration Pack 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 23, 2022, to 
June 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the HIPPS code was not properly billed on the 
claim. 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 home health services rendered from May 
23, 2022, to June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of epidural neurostimulator 
electrode array (63650 x 2), and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve spinal cord stimulator (SCS). You say that the requested procedure is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as 
therapies for the relief of certain chronic intractable pain. 
 
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 spinal cord stimulator (SCS). Our 
reviewer says that the requested SCS is not medically necessary. Our physician reviewer found that the 
provided documentation does not support that the enrollee has an evidence-based indication for a spinal cord 
stimulator (SCS) trial. Therefore, the reviewer found that the requested SCS is not medically reasonable or 
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 spinal cord stimulator (SCS) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous implantation of epidural neurostimulator electrode array 
(63650 x 2), and implantable neurostimulator electrode (L8680).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse the allowance for scratch resistant coating (2760), a miscellaneous 
vision item or service (V2799), anti-reflective coating (V2750), and progressive lens (V2781) provided on 
September 6, 2022. 
 
You asked the Plan to reimburse the allowance for scratch resistant coating (2760), a miscellaneous vision item 
or service (V2799), anti-reflective coating (V2750), and progressive lens (V2781). You say that you did not 
know that the deluxe items had to be billed with standard codes for coverage. You also say you feel you should 
be reimbursed the $150 for your allowance. The Plan denied your request. The Plan says that you receive a 
$200 allowance per calendar year towards routine eyewear or contact lenses. 
 
The Vision care benefit section of the Medicare Benefits Chart says that the Plan will provide reimbursement 
for up to a $150 allowance per calendar year towards the purchase of eyeglasses or contact lenses. The Plan 
contract says that the enrollee may choose to see any provider licensed to perform these services. The Plan does 
not disclose in clear accurate terms that the benefit for eyewear is limited to routine eyewear. You can find this 
information on page 106 of the Plan's 2022 Evidence of Coverage (EOC). 
 
The Plan references language on page 124 of the EOC that says that the enrollee receives a $150 allowance per 
calendar year towards routine eyewear or contact lenses. However, this language is listed under a column that 
says, covered only under specific conditions and is not clear that the $150 benefit referenced in the vision 
care section of the contract is exclusive to routine eyewear. It just says that there is coverage for routine care 
eyewear or contact lenses. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. The Plan has not substantiated their denial reason, nor have they demonstrated that the benefit for 
eyewear has been exhausted. Therefore, we decided that the Plan has to reimburse the allowance for scratch 
resistant coating (2760), a miscellaneous vision item or service (V2799), anti-reflective coating (V2750), and 
progressive lens (V2781) provided on September 6, 2022.  
 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has hypertrophy of nasal 
turbinates and nasal congestion. There is insufficient literature to support the safety and efficacy of the 
requested service for the enrollee's specific conditions. The records do not support that the VivAer procedure is 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a VivAer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on August 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was used during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The claim information shows the services at issue were provided in an ambulatory surgical center. Neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and related supplies provided on August 4, 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 services are necessary for the enrollee to receive 
ongoing gate training to increase mobility and ambulation tolerance. The Plan denied your request. The Plan 
says the services the enrollee needs can be provided safely in another setting such as a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies.  While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for January 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87801 is not supported. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not support 
that multiple organisms were tested via amplified probe(s) technique. 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 procedure code 87801 billed for January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. 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. 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 panniculectomy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has had weight loss following bariatric surgery. The record 
provided does not document that the panniculus hangs below the level of the pubis and that the panniculus 
causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or 
chafing that consistently recurs or remains refractory to appropriate medical therapy (e.g. topical antifungals, 
corticosteroids, antibiotics) over a period of 3 months. The record does not document that the weight has been 
stable for a six-month period. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
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 enrollees medical necessity is too 
complex to be managed at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's 
records do not show it is medically safe to go to an LTACH. 
 
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 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. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on September 20, 2022. 
 
You asked the Plan to pay for radiology services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on September 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for radiology services 
provided on September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 1, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from February 1, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from 
February 1, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of February 1, 2023, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond February 1, 2023, as he was not a 
danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from February 1, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 1, 
2023, forward.