Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial inpatient hospitalization services. 
 
You asked the Plan to pre-approve partial inpatient hospitalization services. You say that you have been 
feelings worse in the last six weeks. The Plan denied your request. The Plan says you do not meet criteria for 
the requested services. 
 
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 partial inpatient hospitalization 
services. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the documentation does not support that you are 
showing any dangerousness to yourself or others and are not exhibiting any current psychological or 
psychiatric impairment. You have not been showing any moderate dysfunction in family, social environment, 
or performance of daily living skills. You were not showing any dangerousness to self or others tolerating 
medication and not showing any perceptual disturbance, psychosis or aggressive behaviors. It does not appear 
medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care 
rather than a lower level of care. Based upon review the records provided, you do not meet the criteria for 
treatment at partial hospitalization level of care and could be treated in a lesser restrictive setting as you were 
not showing any suicidal or homicidal ideation and was not showing any psychosis or aggressive behaviors 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial inpatient hospitalization services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve partial inpatient hospitalization services.
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 is not medically 
necessary. 
 
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 your medical status does not require intensive physician and nursing oversight in an 
IRF. While you may benefit from additional multiple therapies, including physical and occupational therapy, 
the documentation does not reveal that you require this therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neck surgery. 
 
You asked the Plan to pre-approve neck surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
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 neck surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures directed to the cervical spine. Additionally, the 
objective findings on the examination did not fully demonstrate severe and/or progressive neurological deficits. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the request for anterior cervical discectomy and fusion at C5/6 and 
C6/7 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 neck surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve neck surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transversus abdominis plane block services (64488-59) 
provided on July 21, 2021. 
 You asked the Plan to pay for transversus abdominis plane block services. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the use of the 
modifier for separate payment was not supported. 
 
In this case, we have confirmed that code 64488 is a column II code to column I code 00840 however, 64488 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the transversus abdominis plane block services. Our reviewer 
says that the documentation does not support payment for the services as billed. Our reviewer found that the 
documentation does not support this procedure was separate from anesthesia services per Medicare 
guidelines.  64400-64530 (Peripheral nerve blocks  bolus injection or continuous infusion) CPT codes 64400-
64530 (Peripheral nerve blocks  bolus injection or continuous infusion) may be reported on the date of surgery 
if performed for postoperative pain management only if the operative anesthesia is general anesthesia, 
subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent 
on the peripheral nerve block. 
 
We looked at this coder's review, the file, and Medicare rules. 
 
Therefore, we decided that the Plan does not have to pay for transversus abdominis plane block services 
(64488-59) provided on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the information provided supports the 
need for LTACH care. You say that an LTACH is the appropriate level of care and the most optimal 
opportunity for a successful outcome for the enrollee. The Plan denied your request. The Plan says they 
recommend the enrollee stay in the hospital for now, based on his current needs. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care facility. 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 health plan has approved ongoing care 
in the current acute care facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home dialysis care services. 
 
You asked the Plan to pre-approve home dialysis care services. You say that this is medically necessary for 
your continued care. The Plan denied your request. The Plan says this service is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that staff assisted home dialysis is not covered. 
 
We looked at the file and Medicare rules. Medicare does not provide coverage for home dialysis. Based on this 
information, we decided that Medicare rules for coverage of home dialysis care services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home dialysis care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable panel system for a lower limb prosthesis 
socket (L5999). 
 
You asked the Plan to pre-approve the adjustable panel system. You say that this feature is medically 
necessary. The Plan denied your request. The Plan says the requested code cannot be used to bill additional 
features. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5999 (Lower Extremity Prosthesis, Not 
Otherwise Specified) must not be used to bill for any features or functions included in the socket or addition 
codes. 
 
We looked at the file and Medicare rules. The requested is for a lower extremity feature using code L5999. 
Based on this information, we decided that Medicare rules for coverage of the adjustable panel system have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an adjustable panel system for a 
lower limb prosthesis socket (L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve SI joint injections. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been 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 SI joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are a 64-year-old man with right hip pain. In this case, there is insufficient 
physical exam findings and imaging to support an SI joint injection. The request 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 SI joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sacroiliac (SI) joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no 
longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient care from June 9, 2022, forward was requested. 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 continued services. Our physician reviewer found that you were admitted to 
the acute inpatient psychiatric hospitalization with major neurocognitive disorder, unspecified with behavioral 
disturbance and delirium. It is not expected that you would improve in a reasonable period of time for the dates 
in question as you did not have suicidal or homicidal ideation, auditory or visual hallucinations.  
 You were compliant with treatment while not showing any acute threats to safety. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as you did not have dangerousness to self or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve a continued SNF stay. You say that the enrollee needs daily skilled therapy 
services. You also say that the enrollee's needs are greater than can be met in an assisted living home, and in 
home care would require full time skilled help, which the enrollee cannot afford. The Plan denied your request. 
The Plan says the SNF services you are requesting 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 a continued SNF stay. Our reviewer 
says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued SNF stay have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continued skilled nursing facility (SNF) stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear mold/insert (V5264) provided on December 20, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ear mold/insert. You say that you have been going to this same provider since 
2016 and would like this bill to be paid. The Plan denied your request. The Plan says these hearing aids were 
rendered by an OON provider. The Plan also says that you did not contact the customer service department or 
the Plan's hearing aid vendor prior to purchasing the hearing aids to confirm benefits or to register for the aids, 
other than the call that occurred on August 24, 2021 where you were informed that you would need to conduct 
a purchase with the Plan's approved hearing aid vendor in order for it to be covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the ear mold/insert have not been met. Therefore, we decided that the Plan does not have to pay for 
the ear mold/insert (V5264) provided on December 20, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that two separate and distinct procedures were 
performed. The Plan denied your request. The Plan says bundled services 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 44389 is colonoscopy through stoma; with biopsy, single 
or multiple. We find that CPT codes 44389 and 44392 have the same base procedure, which means multiple 
endoscopy rules apply.  and is not supported in the medical record. Therefore, we decided that the Plan does 
not have to further pay for the colonoscopy services provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the  Kenalog-40 Injection (J3301, 96372), provided on 
March 11, 2021. 
 
You asked the Plan to pay for the Kenalog-40 Injection. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is 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 pay for the Kenalog-40 Injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature states that treating seasonal allergic rhinitis with depot-steroid injections should be 
abandoned and replaced with immunotherapy, as annual depot-steroid treatment is associated with increased 
risk of diabetes and osteoporosis.  
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 Kenalog-40 Injection have not been met. Therefore, we decided that the 
Plan does not have to pay for the  Kenalog-40 Injection (J3301, 96372), provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on September 3, 2021. 
 
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says your mandatory 
supplemental vision benefit exclusions include any benefits received at a non-network optical provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were provided by a non-network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on  
September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that denial of an inpatient hospital 
admission would put the enrollee at high risk. The Plan denied your request. The Plan says the requirements for 
an inpatient admission have not been met. The Plan says that the enrollee does not have a serious injury from 
the fainting spell that would require monitoring in the hospital, nor does she have a dangerously show heartbeat 
that needs monitoring in the hospital. The Plans says that emergency room observation services have been 
approved. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission have been met 
in this case. Our physician reviewer found the enrollee presented to the hospital on May 9, 2022, with 
weakness and dizziness where she nearly passed out. She was found to have a low heart rate where the heart 
beats were being blocked and Cardiology was consulted. She was given intravenous (IV) antibiotics and placed 
on heart monitoring overnight. Her condition stabilized and improved, and she was discharged May 10, 2022, 
with outpatient follow-up. The record did not show that at the time of the request for an inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.