Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixteen (16) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that additional physical therapy is medically 
necessary as a new sacrum fracture has been diagnosed. The Plan denied your request. The Plan says the 
requested physical therapy is not medically necessary. The enrollee can walk over 1,000 feet, can flex 110 
degrees at the trunk, can extend 25 degrees, and has been instructed on and found to be independent in a home 
exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the Plan. The enrollee 
has had prior therapy, and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can only be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee is 
independent in a home exercise program (HEP). The requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the enrollees current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sixteen (16) additional physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing 
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical 
matter you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve skin lesion removal provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pre-approve the surgery. You say that this was medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this request is a standard of care for the type of vascular lesions that the enrollee has. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve skin lesion removal provided to the enrollee on November 2, 2021.  
 
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 total right knee replacement. 
 
You asked the Plan to pre-approve the requested knee replacement surgery. You say that this is medically 
necessary at this time. The Plan denied your request. The Plan says there is insufficient evidence to support the 
need for this procedure. There is no documented failure of appropriate conservative treatment. 
 
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 requested knee replacement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 65-year-old female was being treated for unilateral primary 
osteoarthritis of the right knee. She presented with right knee pain. The symptoms have worsened since the last 
visit. The pain is moderate with a rating of 5/10. The pain has increased and is worse. The pain is located along 
the inferior patella. She was advised to avoid non-steroidal anti-inflammatory drugs (NSAIDs) by her primary 
care physician. The right knee exam reveals tenderness to palpation anterior medial joint line. There is crepitus 
noted and trace effusion. Range of motion is decreased to 5-110 with pain on deep knee flexion.  
 However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There is limited published, large-scale, long-term 
peer-reviewed literature that shows total knee replacement to be an effective and/or safe treatment for the noted 
pathology without trial and failure of conservative treatment. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested total right knee replacement, in this case, 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 the requested knee replacement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a total right knee replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services you provided on December 8, 2021. 
 
You asked the Plan to pay for wound care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services would not be considered as urgent or emergent services. 
The benefit had been exhausted prior to this service and the member had been notified previously by the Health 
Plan via notice of denial. 
 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. 
 
We looked at the file and the Plans rules. The requested provider in this case is not a network provider with 
the Plan. The Plan did not pre-approve the wound care services. The POS benefit had been exhausted prior to 
this service. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for wound care services provided on December 8, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for pulmonary embolism and right shoulder pain.  Your medical problems are stable. 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 you have 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on August 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that this is separately identifiable from other 
services. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code G0180 was billed on the same date as code 99350. We find that CPT code 
G0180 may be eligible for payment when billed with this code pair. The claim information does not show that 
the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2300, V2782, V2744, V2750) 
provided on December 10, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that these new eyeglasses were necessary, and you feel 
you should not owe more than you have already paid for these services. The Plan denied your request. The Plan 
says they have paid the full $300 annual benefit allowance for these services, and you are responsible for the 
remaining cost. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 per year toward the cost of contacts, frames, eyeglass lenses, and eyewear 
upgrades at participating network providers. 
 
We looked at the file and the Plan's rules. The documentation in this case shows that the total cost of the 
eyewear purchased on December 10, 2021, was $555. The record shows that the Plan has paid the full $300 
allowance amount. Please note that the explanation of benefits sent by the Plan is not a bill, but a document to 
explain how the Plan has processed your claim and show the maximum amount the provider is allowed to bill. 
This means the Plan has paid the correct amount for the eyeglasses. Therefore, we decided that the Plan does 
not have to pay any additional amount for the eyeglasses (V2020, V2300, V2782, V2744, V2750) provided on 
December 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services, basic life support, 
emergency transport (A0429) provided on November 21, 2021. 
 
You asked the Plan to waive the copayment for ambulance services, basic life support, emergency transport. 
You say that were sent back to the hospital due to infection that was not addressed the first admittance, so you 
should not have to pay due to would have been released from rehabilitation on November 25, 2021. The Plan 
denied your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered ground trip for ambulance services.  
 You have been asked to pay a $250 copayment for ambulance services, basic life support, emergency transport. 
Ambulance services, basic life support, emergency transport falls within the ambulance services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance services, basic life support, 
emergency transport (A0429) provided on November 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular surgery services provided on May 5, 2021, 
billed with codes 35355 and 34709. 
 
You asked the Plan to pay for the surgery services as billed. You say that these services were billed correctly 
and should be paid. The Plan denied your request. The Plan says the coding is not supported by the operative 
report. 
 
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 35355 is thromboendarterectomy, including patch graft, 
if performed; iliofemoral.  
 
 
 
 The definition of code 34709 is placement of extension prosthesis(es) distal to the common iliac artery(ies) or 
proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false 
aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective 
catheterization(s), all associated radiological supervision and interpretation, and treatment zone 
angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary 
procedure). 
 
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 surgery services as billed. Our reviewer says that the 
services billed are not supported by the records. Our reviewer found for code 35355, the operative report does 
not include enough documentation to support a thromboendarterectomy, iliofemoral was performed. The 
language in the report does not match the description of the procedure from the NCCI manual.  
 
For code 34709, the operative report does not include enough documentation of procedure to confirm a 
placement of extension prosthesis distal to the common iliac artery or proximal to the renal artery for 
endovascular repair was performed.  NCCI Policy Manual guidelines state "an extension prosthesis is placed 
distal to common iliac artery or proximal to the renal artery for endovascular repair of an infrarenal abdominal 
aortic or iliac aneurysm, pseudoaneurysm, dissection or penetrating ulcer that terminates in the internal iliac, 
external iliac, or common femoral arteries or in abdominal aorta proximal to the renal arteries". This is not 
described in the operative report. 
 
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 surgery services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the vascular surgery services provided on May 5, 2021, billed with codes 35355 
and 34709.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on October 13, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were unaware that there was a benefit 
limit. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted. 
 
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 Plan covers a limited oral 
evaluation once per plan year. 
 
We looked at this physician's review, the file, and Medicare rules. Evidence was provided to show that D0140 
was provided on January 22, 2021. Based on this information, we decided that the Plan's rules for coverage of a 
limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) provided by an out-of-network provider on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a BiPAP device. We decided that the Plan does not have to pre-
approve services beyond 3 months.  
 You asked the Plan to pre-approve a BiPAP device. You say that other alternative treatments were found 
ineffective during his hospital stay. The Plan says that the records do not support medical necessity. 
 
We decided that the Plan has to pre-approve a BiPAP device.  
 
The Plan follows Medicare rules. Medicare rules say that a BiPAP device is only covered under certain medical 
indications. 
 
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 BiPAP device. Our physician 
reviewer found that you have had recent hospitalizations for acute on chronic respiratory failure with carbon 
dioxide (CO2) retention. The most recent was in the setting of Covid-19 pneumonia. There is a possible 
diagnosis of COPD, although the lung exam is normal and there are no pulmonary function tests. There are 
possible diagnoses of obstructive sleep apnea and obesity hypoventilation syndrome. There is no arterial blood 
gas (ABG) done as an outpatient while stable to confirm chronic CO2 retention. It is reasonable to begin home 
BiPAP to reduce the risk of further hospitalizations while obtaining the outpatient ABG, pulmonary function 
tests, and polysomnography. Therefore, a home BiPAP is considered reasonable and necessary for 3 months, 
with additional testing as an outpatient to confirm continued need.  
 
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 BiPAP device have been met. Therefore, we decided that the Plan has to pre-
approve a BiPAP device.  
 
We also decided that the Plan does not have to pre-approve services beyond 3 months. 
 
The Plan follows Medicare rules. Medicare rules say that BiPAP device is only covered under certain medical 
indications.  
 
We looked at the file, and Medicare rules. Medicare will not continue coverage for the fourth and succeeding 
months of therapy until a re-evaluation has been completed. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve services beyond 3 months. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ampyra. 
 
You asked the Plan to pre-approve Ampyra. You say that the requested drug is medically necessary and 
supported by the records provided. The Plan denied your request. The Plan says the enrollee does not have a 
pharmacy benefit administered under this contract. The Plan says that the enrollee has TRS-Care MA which 
provides its own 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 Ampyra.  
 Benefits for Ampyra 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says Eliquis is a self-
administered drug and does not fall under Part B 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 Eliquis.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.