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 enrollee was admitted following trauma with a right 
humorous fracture, right 3-5 rib fracture and Hypoxemia respiratory failure. Worsening diffusion chest tube has 
been removed. The enrollee would benefit from inpatient rehabilitation to learn transfers, become stronger with 
non-weight bearing RHE. The Plan denied your request. The Plan says the request is not medically necessary. 
You can safely receive the services you need in other settings. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and 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 inpatient rehabilitation services are medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are 
not met in this case. The enrollee can safely receive the necessary services in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has complex functional impairments with an IRF-compliant diagnosis and active medical issues; however, the evaluating therapists 
document multiple therapy refusals and recommend less intense therapy in a sub-acute setting. IRF criteria are 
not met in this case as the enrollee would not be expected to tolerate an intense therapy 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 inpatient rehabilitation facility (IRF) admission and 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's 
condition; the enrollee does not meet the requirements. 
 
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 complexity of the enrollees 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 urinary tract infection, obstructive uropathy, and anemia and was discharged home 
on October 27, 2022. The enrollees 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 medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of recurrent prostate cancer or radiation therapy treatments. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee is newly diagnosed with prostate cancer and has 
not received radiation therapy. The record does not indicate that the enrollee has an enumerated condition for 
which coverage of the requested service is available. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high intensity focused ultrasound (HIFU).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  extra one-way transportation trips. 
 
You asked the Plan to pre-approve extra one-way transportation trips. You say that you have an upcoming 
appointment, and other appointments for the remainder of the year. You also say you are visually impaired, and 
need assistance. The Plan denied your request. The Plan says your Plan benefit allows for 30 one-way trips per 
plan year for routine non-emergency visits to plan approved locations such as a doctor's appointment. The Plan 
also says that extra one-way transportation trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 on-way trips to plan-approved locations every year trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve  extra one-way transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit (99285) provided March 10, 
2022. 
 
You asked the Plan to pay for the emergency visit. You say that the claim was paid at a lower level, and you 
disagree with the review. please review and reconsider payment of the claim. The Plan denied your request. 
The Plan says the criteria was not met for CPT 99285 as the enrollee was ultimately discharged home in stable 
condition without no risk or threat to life. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.  
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency visit. Our reviewer says that 
the Medicare criteria for coverage of CPT code 99285 was not met. Our reviewer found the medical records do 
not support the level of 99285, which requires 3 of 3 requirements a detailed history; a detailed examination; 
and medical decision making of comprehensive. These requirements were not met based on the documentation 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for emergency department visit (99285) provided March 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you are in pain every day. The Plan denied your 
request. The Plan says you have not tried on of the preferred drugs. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monovisc. Our physician reviewer 
found that you have bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc, 
Synvisc, or Synvisc One before they will approve the requested drug. The case file does not contain 
documentation of trial and failure of the Plan's required drugs. The documentation does not support that the 
Plans required drugs would likely be less effective or would likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you do physical therapy 3 times a week and you 
do the exercises at home, but you are still in a lot of pain. The shoe inserts, ordered by your provider, are to 
help with your medical condition of plantar fascial fibromatosis and posterior tibial tendinitis of the right leg. 
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 pre-approve foot inserts/orthotics (L3020).
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 IRF care is medically necessary, and the enrollee 
may not fully recover without the rehabilitation. The Plan denied your request. The Plan says the IRF care is 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain their functional status. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95822) provided on 
March 9, 2020. 
 
You asked the Plan to pay for procedure code 95822. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing 
of code 95822. 
 
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 95822 is Electroencephalogram (EEG); recording in coma or sleep only. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95822. Our reviewer found the 
documentation does not support the use of procedure code 95822 and therefore cannot be warranted to code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95822 have not been met. Therefore, we decided that the Plan 
does not have to pay for the Electroencephalogram (EEG) (95822) provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt and recline with electronic connection and 
adjustable angle footplates for a wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power tilt and recline is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that you are 
at high risk for a skin breakdown, have a history of pressure ulcers, or have had skin flap surgery to meet the 
criteria for coverage of the power tilt and recline. You do not perform bladder self-catheterization or have 
increased muscle tone or spasticity. You have adequate upper body strength and are able to operate the 
wheelchair's power options with their own switches. The power tilt and recline is not reasonable or 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 these services have not been met.  
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The requested adjustable angle foot plates are not covered because they are included in the approved 
wheelchair items. The adjustable angle foot plates would be duplicate equipment. 
 
Therefore, we decided that the Plan does not have to pre-approve a power tilt and recline with electronic 
connection and adjustable angle footplates for a wheelchair.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says according to the available records, the enrollee does not meet all the 
required Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
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 enrollee needs SNF care. The Plan denied your 
request. The Plan says medical necessity for SNF was not met because records do not show a need for either 
skilled nursing or rehabilitation care daily. 
 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 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 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 skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886, 95908, 95937 and 95955 billed for 
date of service April 7, 2022. 
 
You asked the Plan to pay for procedure codes 95886, 95908, 95937 and 95955. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
as billed. 
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure). The definition of code 95908 is nerve conduction studies; 
3-4 studies, the definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method, and the CPT Code Manual definition of code 95955 is 
electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 95886, 95908, 95937 and 95955. Our 
reviewer says that the Plan's denial appears appropriate in this case. Our reviewer found the medical records do 
not support the procedure codes billed. There are more appropriate codes which more accurately reflect the 
services provided/reported in the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95886, 95908, 95937 and 95955 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95886, 95908, 95937 and 95955 billed for 
date of service April 7, 2022.