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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 valve replacement. 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 the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 office visit rendered on March 10, 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 services are not payable under OPPS. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 99211 has an OPPS status indicator of B, 
signifying it is not recognized by OPPS and is thus not payable. Therefore, we decided that the Plan does not 
have to pay for the office visit rendered on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in PS 
with Safety Tidal Volume mode without Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with bacterial endocarditis and pneumonia. COPD exacerbation is listed as a diagnosis, although there are no 
pulmonary function tests. ABG in the hospital was consistent with acute on chronic hypercarbic respiratory 
failure. The enrollee may benefit from BiPAP during sleep as an outpatient. The PS mode with safety tidal 
volume can be delivered by BiPAP.  Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. 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. Medically necessary care can be provided in a different level of care. 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. 
 
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 surgery services provided on April 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the enrollee needed the services you provided 
after their surgery. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no referral from an in-network provider or an approved authorization. Also, the service rendered was 
not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgery services provided on April 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim processed for payment 
because the service rendered to the enrollee was medically necessary. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON providers and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for taxi service, pharmacy drugs and ankle wraps 
provided from March 3, 2022, to March 7, 2022. 
 
You asked the Plan to reimburse you for taxi service, pharmacy drugs and ankle wraps. You say that these 
services were medically necessary. The Plan denied your request. The Plan says taxi service, pharmacy drugs 
and ankle wraps are not a covered benefit. 
 
The Plan contract covers emergency and urgently needed services worldwide. The Plan says services must 
meet the same Medicare criteria applied to emergency or urgent care services received within the Unity States 
and its territories. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation is only covered when 
the supplier meets the applicable vehicle, staff, and billing and reporting requirements. 
 
 We looked at the file, the Plans rules and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of taxi service, pharmacy drugs and ankle wraps have not been met. The Medicare 
transportation benefit is limited to transportation by a fully equipped ambulance with appropriately trained 
staff. The file shows that the transportation requested is with a taxi. This means that the service at issue is not a 
covered benefit of Medicare or the Plan. Pharmacy drugs and ankle wraps are not emergently needed or urgent 
care services. Therefore, we decided that the Plan does not have to reimburse you for taxi service, pharmacy 
drugs and ankle wraps provided from March 3, 2022, to March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership (S9970) purchased on 
August 14, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the membership purchased is not covered 
under the enrollees contractual policy. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
 
 The Plans rules for coverage of gym benefits have not been met. Specifically, the Plan benefit provides 
coverage of yoga fitness classes but not for a yoga instructor trainee program purchased in this case. Therefore, 
we decided that the Plan does not have to issue reimbursement for the gym membership (S9970) purchased on 
August 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and attachments. 
 
You asked the Plan to pre-approve these services. You say that these are medically necessary. The Plan denied 
your request. The Plan says that you do not meet criteria for tilt and recline features and therefore do not meet 
criteria for base code power wheelchair group 3 with multiple power options. 
 
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 requested services are not considered medically reasonable and necessary in this case. Your skin sensation, 
skin integrity and skin condition are intact with no current ulcers or history of skin ulcerations. Records do not 
document that you perform bladder self-catheterization or that you have increased muscle tone or spasticity. 
Thus, there is no documentation of need for power tilt and recline and no need for the multiple power options. 
Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair with multiple power options and attachments.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation and lodging services you received from 
April 25, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 the Plan only covered 
transportation and lodging for transplant services. 
 
Review of the file shows that you incurred transportation and lodging expenses from April 25, 2022, to April 
28, 2022. These expenses were for cancer treatments, not transplant services. This is not a covered benefit under your plan. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. Therefore, we decided that the Plan does not have to pay for the transportation and lodging services 
you received from April 25, 2022, to April 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain 
(including brain stem); without contrast material (70551) provided on November 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says traditional Medicare is responsible for hospice 
services until the end of the month when the beneficiary revokes or is discharged from hospice alive. 
 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 November 15, 2021. The service in question was provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) of the brain (including brain stem); without contrast material (70551) provided on 
November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29823 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 29823. You say that code 29823 is documented in the operative 
report and this code is payable per NCCI edits. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says this code is not supported in the medical record. 
 
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 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator 
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
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 procedure code 29823. Our reviewer says that this code is 
not supported by the medical record. Our reviewer found the areas described were not separate or distinct from the joint the provider was performing the arthroscope on. The medical documentation could does not describe 
the use of this procedure 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 29823 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 29823 billed for date of service April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day CGM sensor. You say that the enrollee has type 2 
diabetes mellitus and needs the requested sensor. The Plan denied your request. The Plan says the enrollee does 
not meet prior authorization criteria requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14 Day CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 Day continuous glucose monitor (CGM) sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72100] billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 72100]. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72100] is bundled into payment for 
code 72110. 
 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 
72100] is a column II code to column I code 72110. 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 72100] billed for date of service March 30, 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 it is felt that IRF care would be the best option for 
this enrollee. The Plan denied your request. The Plan says the criteria for IRF care have not been met. 
 
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 is a male with a history of chronic renal failure who presented to the hospital due to cellulitis, acute on chronic renal failure, hyperkalemia, and confusion due to metabolic 
encephalopathy. The enrollee was started on dialysis; it was recommended that this be continued longer-term.  
 
At this time, the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires multiple 
therapies, including physical therapy and occupational therapy, but does not require at least 3 hours a day/5 
days a week, or 15 hours over 7 consecutive days, of therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided on May 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that your plan has paid you previous reimbursements 
for services from this provider. You say that you understand the provider is not part of the plan. You say that 
you have been seeing this provider since 2008. You also say that switching to another doctor could be 
detrimental to your health and mental stability. The Plan denied your request. The Plan says there has been no 
previous payment to the provider in this case. The Plan says prior authorization was not obtained before the 
service was rendered. The Plan also says the service could have been provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided 
on May 17, 2022, by an out-of-network (OON) provider.