Persius/hicric huggingface dataset:
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 does not require treatment by multiple therapies, including either 
physical or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have 
a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesnt support that she would meet criteria for admission to an acute inpatient 
rehabilitation facility. The enrollee can receive further services 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 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 an expandable controller (E2377), electrical harness 
(E2313), seat elevator (E2311), electronic connection (E2311), attendant control (E2331), adjustable height 
joystick bracket (K0108), foot plate (K0108), outside edge Footplate extension (K0108), arm stops (K0108), 
egg switch (K0108), and seat liner (K0108). 
 
You asked the Plan to pre-approve an expandable controller, electrical harness, seat elevator, electronic 
connection, attendant control, adjustable height joystick bracket, foot plate, outside edge Footplate extension, 
arm stops, egg switch, and seat liner. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, electrical 
harness, seat elevator, electronic connection, attendant control, adjustable height joystick bracket, foot plate, 
outside edge Footplate extension, arm stops, egg switch, and seat liner. Our reviewer says that the services are 
medically necessary. Our physician reviewer found the enrollee has sufficient strength to manage standard 
switches, the attendant electronics are not medically necessary, and the seat lift is not medically necessary. The 
enrollee manages with a standard joystick and the egg switch 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 an expandable controller, electrical harness, seat elevator, electronic connection, 
attendant control, adjustable height joystick bracket, foot plate, outside edge Footplate extension, arm stops, 
egg switch, and seat liner have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an expandable controller (E2377), electrical harness (E2313), seat elevator (E2311), electronic connection 
(E2311), attendant control (E2331), adjustable height joystick bracket (K0108), foot plate (K0108), outside 
edge Footplate extension (K0108), arm stops (K0108), egg switch (K0108), and seat liner (K0108).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient physical therapy services provided from September 6, 
2021, through September 27, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that the records submitted support the 
billed services. The Plan denied your request. The Plan says that none of the codes that are billed are 
documented as being performed in the records. 
 
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. The denial rationale in this case is that the records provided do not support the 
billed codes. However, review of the records clearly show documentation from the physical therapy assistant 
for all the services billed on the dates of service listed on the claim. The Plan does not specifically indicate the 
reason that the documentation which corroborates the billed services is not valid. Based on review of the 
records, the billed therapy services are supported. Therefore, we decided that the Plan has to pay for the 
outpatient physical therapy services provided from September 6, 2021, through September 27, 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: 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 admission is a medical necessity.  The Plan denied 
your request. The Plan says according to the information reviewed on appeal, the requested services are 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 the enrollee does not require the intensity of services provided at an IRF.  
 Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitive services and regular 
physician evaluation. The enrollee's care needs can be met 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on June 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 a telehealth visit provided on June 2, 2021, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 
providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00731) provided to the 
enrollee on May 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says based on the Medicare guidelines, CPT 00731 would be inappropriate to allow. 
 
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 00731 is "Anesthesia for upper gastrointestinal 
endoscopic procedures, endoscope introduced proximal to duodenum, not otherwise specified." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that anesthesia services were 
reimbursed for same date of service. The medical record does not support two separate anesthesia services 
performed.  When different procedures are performed, the most comprehensive anesthesia code would be 
reported. In this case CPT 00731 cannot be verified.   
We looked at this coder'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 anesthesia services (procedure code 00731) provided to the enrollee on May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization procedures (37220, 
37221, 37222, 37223, 37224, 37225, 37225, 37227, 37228, 37229, 37231, 37233, 76937, 75630, 37252, 
37253). 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that while the patient has a history of leg discomfort, the documentation does not confirm the 
presence of severe disease, nor has there been a trial of medical therapy and risk factor management. In 
summary, there is insufficient documentation to support the medical necessity for lower extremity angiography 
and revascularization in this patients 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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovascular revascularization procedures (37220, 37221, 37222, 37223, 37224, 37225, 
37225, 37227, 37228, 37229, 37231, 37233, 76937, 75630, 37252, 37253).
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 enrollee needs a higher level of care than an 
assisted living facility and would benefit from a SNF level of care. The Plan denied your request. The Plan says 
SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilling nursing and/or skilled therapy 
services. The enrollee is medically stable and can receive further rehabilitation services 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 SNF care.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says Medicare SNF criteria are not met in this case. 
 
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 was admitted to the hospital on November 27, 2022, due to syncope. As 
of the time of the request for SNF, the enrollee does not have documented skilled nursing needs. The enrollee 
does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a compounded drug provided to the enrollee on January 4, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use. 
 
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 J7999 is "Compounded drug, not otherwise classified." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the billing record supports 
Healthcare Common Procedure Coding System (HCPCS) J7999 was reported with NDC 66794016002 and in 
this case, there is a more appropriate code to report - J2274. Therefore, HCPCS J7999 cannot be verified. 
 
We looked at this coder'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 a compounded drug provided to the enrollee on January 4, 2022.
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 enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as skilled nursing facility (SNF), home health or home 
with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 08, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you shouldnt have to pay 
for this. 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 $265 
copayment for Ambulance services. 
 
You have been asked to pay a $265 copayment for ambulance transport. This item/service falls within the 
Ambulance services 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 ambulance transport 
provided on June 08, 2022.
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. The Plan denied your request. The Plan says based on the 
information available you do not meet the criteria for admission to a SNF facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you had a fall without significant injury and are very near your baseline. You do not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. Our reviewer also found that you do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 
03, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. 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 $50 
copayment for Specialist office visits. 
 
You have been asked to pay a $50 copayment for specialist office visit. This item/service falls within the 
Specialist office 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 specialist 
office visit provided on August 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you feel these are medically necessary and should be 
covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.