Persius/hicric huggingface dataset:
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 member's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the member does not meet the Medicare criteria 
for an IRF 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 the records show that the enrollee is able to function outside of the home and is 
independent with activities of daily living. The current functional level is such that outpatient therapy would be 
sufficient, and admission to an inpatient therapy unit is not 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 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 the continuation of skilled nursing facility (SNF) care 
from April 13, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 you did not have any parental medications, complex wound care or nutrition given 
via a feeding tube. Your function had plateaued until the weight-bearing restrictions were lifted and you could 
be discharged to a lower level of care for further services. As of April 12, 2023, you required custodial 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from April 13, 2023, forward.
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. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that SNF care is no longer medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollee's condition. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed (E0304), power pressure 
reducing air mattress (E0277), and trapeze bar (E0910). 
 
You asked the Plan to pre-approve the equipment. You say that the enrollee needs these items due to their 
diagnoses. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the durable medical equipment may be covered when 
certain criteria have been 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 the equipment. Our reviewer says that 
the equipment is not medically necessary. Our physician reviewer found there is no documentation that the 
enrollee meets the body weight requirements. The reviewer found the documentation does not support that the 
enrollee has a condition that requires frequent positioning of the bed and mattress to alleviate pain, promote 
good body alignment, prevent contractures or avoid respiratory infections in a way that an ordinary bed is not 
able to. The reviewer found that the enrollee has limited mobility due to their medical condition.  The 
documentation does not support that the enrollee has multiple stage 2 pressure ulcers located on the trunk or 
pelvis and has failed to improve in the previous month with conservative treatment with a comprehensive ulcer 
treatment program or a myocutaneous flap or skin graft. Therefore, the reviewer found that the requested 
equipment 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 equipment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty hospital bed (E0304), power pressure reducing air mattress (E0277), and 
trapeze bar (E0910).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 17311 provided on August 8, 2022. 
 
You asked the Plan to pay for code 17311. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 17311 is Mohs micrographic technique, including 
removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, 
microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with 
surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue 
blocks. 
 
We find that CPT code 17311 is not supported in the medical record. Specifically, this service was billed 
within 90 days of surgical procedure 15260 (Full thickness graft, free, including direct closure of donor site, 
nose, ears, eyelids, and/or lips; 20 sq cm or less). This means code 17311 is considered included within the 
global surgery package of procedure 15260 and it not separately payable as billed. Based on this information, 
we decided that Medicare rules for coverage of code 17311 have not been met. Therefore, we decided that the 
Plan does not have to pay for code 17311 provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service July 13, 
2022.  

You asked the Plan to pay for procedure code 87801. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 87801 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 87801 is a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87801 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87801 billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that this claim was inappropriately down coded. 
The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the group therapeutic procedures (97150), 
office visit (99211), and the durable medical equipment (E1399) provided from September 26, 2022, through 
November 3, 2022. Additionally, the Plan does not have to waive the copayments applied to the chiropractic 
manipulative treatments (98941 x 9) provided from September 26, 2022, through November 3, 2022. 
 
You asked the Plan to issue reimbursement for the group therapeutic procedures, office visit, and the durable 
medical equipment provided. Additionally, you asked the Plan to waive the copayments for the chiropractic 
manipulative treatments provided. You say that you are requesting a reconsideration of the Plan's denial for 
payment. The Plan denied your request. The Plan says the services at issue are not covered by Medicare or the 
Plan. Additionally, the Plan says the copayments have been applied correctly to the chiropractic services 
provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 $20 
copayment for each Medicare-covered chiropractic visit.  
 
The records show that the services at issue are not covered by Medicare or the Plan. Additionally, you were 
asked to pay $180 ($20 copayment x 9) for the chiropractic manipulative treatments provided. 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 issue reimbursement for the group therapeutic procedures (97150), office visit (99211), and 
the durable medical equipment (E1399) provided from September 26, 2022, through November 3, 2022. 
Additionally, the Plan does not have to waive the copayments applied to the chiropractic manipulative 
treatments (98941 x 9) provided from September 26, 2022, through November 3, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test (93018) provided on September 
14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic service. You say that please review and reprocess. CPT code 
93018 is coded correctly and is payable under Medicare guidelines. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient service have been met. 
Medical records were requested from the provider to determine how the enrollee came to the servicing 
provider, whether the services are medically necessary or whether the services were performed as billed. The 
records show that the Plan made multiple attempts to obtain the needed medical records from the provider 
without success. Therefore, we decided that the Plan does not have to pay for the cardiovascular stress test 
(93018) provided on September 14, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that it is not medically necessary for the enrollee to 
control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that the upgraded electronics are medically necessary 
when it is necessary to control the power options through the joystick. 

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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has adequate 
strength in the left upper extremity to manage the standard power drive switches. A single source for control is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation for a total knee 
arthroplasty. 
 
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 there are no large volume, long-
term/high-quality clinical studies that confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
computer-assisted navigation for the approved total knee arthroplasty 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted surgical navigation for a total knee arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 

 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 26, 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 member requires and will benefit from an IRF 
admission. The Plan denied your request. The Plan says the member does not meet the Medicare criteria for an 
IRF 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 laboratory services provided on date of service December 7, 
2022, billed with multiple codes. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the services at issue have been incorrectly 
billed with multiple codes. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on date of service December 7, 2022, billed with multiple codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 30, 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 March 
30, 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 March 30, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 30, 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 enrollees 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 March 30, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 30, 
2023, forward.
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 enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 18, 2022 to 
April 7, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.