Persius/hicric huggingface dataset:
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 member has been diagnosed with dementia. The 
representative also says that as more time elapses with not receiving consistent rehabilitation, her quality of life 
quickly deteriorates and the harder it will be for her to retain maximum function. The Plan denied your request. 
The Plan says based on Medicare guidelines, the Skilled Nursing Facility (SNF) services being requested do 
not meet the requirements for approval.  
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 the enrollee does not have documented skilled nursing or skilled therapy needs. Our 
physician reviewer also found that daily skilled services are not required to establish a maintenance program or 
to prevent deterioration of the enrollee's condition. Our physician reviewer also found that the enrollee's care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implants 
 
You asked the Plan to pre-approve cochlear implants. You say that you are appealing this denial because you 
need this procedure to help you hear better. The Plan denied your request. The Plan says that the records show 
that the enrollee does not meet the Medicare criteria per NCD 50.3 Cochlear Implants. 
 
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 cochlear implants. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee has left ear profound sensorineural 
hearing loss and mild to moderate sensorineural hearing loss on the right that is being treated with a hearing 
aid. The record indicates that the enrollee is using a hearing aid in the right ear. The record notes that the 
provider has indicated that the enrollee does not satisfy the coverage criteria. The elements of the coverage 
criteria are not satisfied and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cochlear implants have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cochlear implants
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the enrollee's current level of function, the enrollee does 
not require an intensive, complex, multidisciplinary approach to daily therapy. The records do not support the 
need for an intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 
days per week. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 
care such as at a skilled nursing facility (SNF), on an intermittent basis at home with home health care, or in a 
long-term care setting. 
 
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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. This is no acute rehabilitation nursing needs 
identified or documented. At the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. The enrollee's rehabilitation needs can be safely addressed in an SNF with similar functional outcome. 
 
Documentation does not support necessity for admission to an IRF. While the enrollee may benefit from 
continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely provided 
in a lower intensity and alternate setting such as in an SNF. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that routine drug testing is necessary to monitor use of 
prescriptions. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested item have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has COPD. An addendum to the medical records indicates the enrollee had tree-in-bud opacities on a 
CT scan of the chest, and therefore the enrollee has bronchiectasis; however, tree-in-bud opacities are not the 
same as bronchiectasis. The records do not include a report of the chest CT scan indicating 
bronchiectasis. There is no mention of bronchiectasis in the remainder of the clinical notes. There is inadequate 
evidence that an HFCWOD is effective in the treatment of COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services provided on January 19, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that there is 
no network deficiency for the services. 
 
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. 
 
We looked at the file and the rules. The provider in this case is not a network provider with the Plan. However, 
the Plan contract says that the enrollee can receive care from an out-of-network provider. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the surgery services provided on January 19, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 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 rib fractures, clavicle fracture and pelvic fractures after a fall. 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 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. 
 
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 pre-approve a repeat caudal epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat injection. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months. 
 
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 repeat injection. Our reviewer says 
that the requested repeat injection is not medically necessary. Our physician reviewer found the provided documentation does not indicate at least 50% sustained improvement in pain relief and/or improvement in 
function measured from baseline using the same scale for at least 3 months. Therefore, the requested repeat ESI 
is considered 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 a repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat caudal epidural steroid injection (ESI) (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
May 31, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you could not 
understand each other due to a bad connection and ended up rescheduling. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 $30 
copayment for telehealth specialist visits. 
 
 
 
 
 
 You have been asked to pay a $30 copayment for the specialist telehealth visit. This item/service falls within 
the telehealth specialist visits 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 the 
specialist telehealth visit provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical extractions (D7210 x2) provided on May 19, 
2022. 
 
You asked the Plan to pay for the surgical extractions. You say that you were not put to sleep for the procedure, 
and your teeth were not surgically removed. The Plan denied your request. The Plan says the dental providers 
office was contacted, and the Plan was advised that the extractions were submitted correctly as surgical. The 
Plan also says that this service is not covered under your plan. 
 
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 two 
surgical extractions (D7210 x2) provided on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132 and 84295 billed for date of 
service February 1, 2022. 
 
You asked the Plan to pay for procedure codes 82435, 84132 and 84295. You say that these services are 
supported as billed. The Plan denied your request. The Plan says payment for codes 82435, 84132 and 84295 is 
bundled into payment for code 80051. 
 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 codes 
82435, 84132 and 84295  are column II codes to column I code 80051. 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 codes 82435, 84132 and 84295 
billed for date of service February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder (ILR). You say that the enrollee will need 
further long-term cardiac monitoring with an implantable loop recorder if atrial fibrillation is captured. The 
Plan denied your request. The Plan says the records do not support that the requested service is 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 the implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that 
continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation (1). At this time, insertion 
of an ILR would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service February 18, 
2022. 
 You asked the Plan to pay for procedure code 92921. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 92921 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92921 billed for date of service February 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92526 billed for date of service September 
24, 2020. 
 You asked the Plan to pay for procedure code 92526. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 92526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92526 billed for date of service September 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve additional PT sessions. You say that the last progress note from PT states 
that progress has been made and the physical therapist is recommending more sessions to further the 
progression made. The Plan denied your request. The Plan says the enrollee recently had PT visits approved. 
The Plan also says to approve more PT for the enrollee, records must be provided showing the enrollee's status 
and if they have made progress during the last approved set of visits. 
 
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 sessions. 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 the enrollee has history of osteoarthritis and chronic low 
back pain, and does not meet the criteria for coverage for the requested additional therapy visits. The 
documentation does not support the need for 14 additional PT visits, which are not medically necessary for 
coverage. Our reviewer also found that chronic low back pain should not need a total of 24 PT visits. 
 
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 sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 additional physical therapy (PT) sessions.