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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on November 7, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were pulled aside because you showed 
signs of COVID-19. You also say that it was a mandatory directive by them because you were suspected of 
being infected that you had to be tested. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.   
We looked at the file and Medicare rules. This testing was required by a cruise line for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of the COVID-19 test have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on 
November 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis treatment provided from November 2, 2021, to 
November 30, 2021 by a foreign provider. 
 
You asked the Plan to pay for the dialysis treatment. You say that you need dialysis and would like help paying 
the bill. The Plan denied your request. The Plan says this is a supplemental benefit not generally covered by 
Medicare. The Plan also says that you must submit proof of payment to the Plan for reimbursement. 
 
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 dialysis treatment provided from 
November 2, 2021, to November 30, 2021 by a foreign provider. have been met. Specifically, you have not 
submitted proof of payment for the services that were rendered. Therefore, we decided that the Plan does not 
have to pay for the dialysis treatment provided from November 2, 2021, to November 30, 2021 by a foreign 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician care planning services provided on January 28, 
2020. 
 
You asked the Plan to pay for physician care planning services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the claim was filed untimely 
due to the COVID-19 public health emergency. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 
 
 The record shows that a claim for physician care planning services was not filed until September 28, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for physician care planning services provided on 
January 28, 2020.
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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The 
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's 
physical function is at or near their baseline and they can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy and office visit services (90834, 99212) provided on 
October 18 to October 30, 2021. 
 
You asked the Plan to pay for psychotherapy and office visit services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not 
been met because the provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states that the provider at issue is not enrolled in the 
Medicare program. This is not correct per Medicare provider records. It is the Plan's responsibility to 
substantiate its denial. In this case, the Plan's denial has not been substantiated and we are not able to 
independently verify the denial rationale. We must therefore find in your favor. Therefore, we decided that the 
Plan has to pay for psychotherapy and office visit services (90834, 99212) provided on October 18 to October 
30, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has already been educated on a home exercise program. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician 
reviewer found that the enrollee is status post spinal surgery. She has been receiving home health physical 
therapy and can ambulate up to 150 feet with a cane. The documentation does not support that she requires 
additional skilled rehab services to effectively provide treatment in order to improve her condition or perform a 
maintenance program to maintain her condition or prevent deterioration. She has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the requested home health 
services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis 
(74176) provided on May 16, 2021. 
 You asked the Plan to pay for the CT of the abdomen and pelvis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 
74176 and 74178. 
 
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 74176 
is a column II code to column I code 74178. 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 the computed tomography (CT) of the abdomen and pelvis 
(74176) provided on May 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neuromonitoring provided to the enrollee on 
May 12, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not submitted with an appropriate diagnosis code. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee in this case was undergoing surgery for low back pain and intraoperative 
neuromonitoring (IONM) services were being provided during the course of the procedure. The enrollee was 
not noted to or suspected of having a disorder of the neuromuscular junction (NMJ). Such a disorder is the 
primary indication for which CPT code 95937 is otherwise utilized. It is otherwise well established that the 
provision of train of four testing during surgery does not meet the CPT definition of the code under review. In 
as much this would not have met criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative neuromonitoring provided to the enrollee on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on February 16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you were told you would not be charged for these services when you asked how much your bill 
was. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant removal with capsulectomy. 
 
You asked the Plan to pre-approve the procedures. You say that the implants have been recalled, and have been 
causing issues. The Plan denied your request. The Plan says the criteria were not met. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you had breast implants for cosmetic reasons in 1975. The record 
indicates that you have joint pain, bad back, brain fog, short term memory loss, intermittent paresthesia and 
generalized pain attributed to the implants. The record does not indicate that you have a condition enumerated in the coverage determination for which coverage is available for the requested service. The elements of the 
coverage criteria are not satisfied.  
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implant removal with capsulectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and a 
CGM supply allowance (K0553) for the enrollee. 
 
You asked the Plan to pre-approve a CGM and a supply allowance. You say that the items are medically 
necessary. The Plan denied your request. The Plan says clinical information from the physician has not been 
received regarding if the enrollee takes insulin or adjust an insulin dose in real time based on the enrollee's 
blood glucose results. 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results or have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM and a supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
(K0554) and a CGM supply allowance (K0553) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 IRF 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for congestive heart failure and atrial fibrillation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has 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 this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre 2 CGM sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) sensor.