Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Patient-Driven 
Grouping Model (PDGM) Health Insurance Prospective Payment System (HIPPS) code 3IB21 provided from 
July 29, 2021, to August 5, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that home health claims must be billed with the correct HIPPS 
code. 
 
We reviewed the file and the Medicare rules. We find that the no medical records were provided to support the 
services billed. No Plan of care, valid orders or visit notes were provided for these dates of service. Based on 
this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services billed with Patient-
Driven Grouping Model (PDGM) Health Insurance Prospective Payment System (HIPPS) code 3IB21 
provided from July 29, 2021, to August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 2, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and an expandable controller (E0953, E0955, E1007, E1012, E1028, E2313, E2361, E2377, E2607, E2620, K0040, K0108, K0861). 
 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and an expandable 
controller. You say that this chair is medically necessary. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 Power Wheelchair with Multiple Power 
Options is medically necessary for individuals that require both power tilt and power recline. 
 
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 group 3 power wheelchair with 
multiple power options and an expandable controller. Our reviewer says that the requested wheelchair is not 
medically necessary. Our physician reviewer found there is no skin breakdown, spasticity, or reliance on 
intermittent catheterization. The enrollee does not meet coverage criteria for power tilt and recline. A simpler 
wheelchair can meet the enrollee's needs. Since the chair is not covered, the expandable controller 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 a group 3 power wheelchair with multiple power options and an expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with multiple power options and an expandable controller (E0953, E0955, E1007, E1012, 
E1028, E2313, E2361, E2377, E2607, E2620, K0040, K0108, K0861).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are medically necessary.  
The Plan denied your request. The Plan says you do not meet the requirements 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 complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatosensory testing (95938) provided on August 3, 
2022. 
 
You asked the Plan to pay for the somatosensory testing. You say that due to the fact that the services meet the 
medical necessity guidelines, you are requesting a reconsideration of the initial denial for payment due for 
services rendered. The Plan denied your request. The Plan says charges for or in connection with services or 
supplies that are, as determined by the Plan, considered to be experimental or investigational are excluded from 
coverage under the enrollee's plan.  
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 somatosensory testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found given the conflicting evidence to date and the overarching consensus that further 
study is necessary to evaluate the use of intraoperative neuromonitoring (IONM) in lumbar spine surgery, the 
requested service is not supported as medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the somatosensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the somatosensory testing (95938) provided on August 3, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be improving with current treatments but is still somewhat 
unstable and should only require short-term additional acute care services that can safely be administered at the 
current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of spinal stenosis and is living at home with trouble ambulating. The 
enrollees medical problems are stable and there are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on September 
20, 2022. 
 You asked the Plan to pay for the DecisionDx-Melanoma testing. You say that this test should be covered for 
the enrollee. The Plan denied your request. The Plan says there is no indication that the requested service is 
medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this test is covered when the enrollee has Stage T1b 
and above or has T1a with documented concern about adequacy of microstaging. 
 
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 DecisionDx-Melanoma testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has T1a 
without concern adequacy microstaging. Thus, the enrollee does not meet the criteria for coverage. 
 
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 DecisionDx-Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on September 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab panel provided on December 16, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says that a panel cannot be 
unbundled and billed as individual components. 
 
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 Plan argues that a panel cannot be unbundled and billed as individual 
components. However, the Plan has not cited a specific Medicare rule for this argument. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
lab panel provided on December 16, 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 services are necessary for the enrollee to receive 
the proper level of care. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as a skilled nursing facility, home with home health services 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition meets full IRF 
criteria. You also say a lower level of care in skilled nursing cannot provide the total interdisciplinary approach 
needed. The Plan denied your request. The Plan says the enrollee does not meet the requirements 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an LTACH level of 
care due to extensive wounds and nutritional status. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for an LTACH admission. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  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 Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on May 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible for payment for assistant surgery services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services 
provided on May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral nasal-tissue cryoablation procedure (C9771). 
 
You asked the Plan to pre-approve nasal-tissue cryoablation. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 nasal-tissue cryoablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient support in the medical literature for the use of bilateral nasal-
tissue cryoablation in the treatment of the enrollee's condition of vasomotor rhinitis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasal-tissue cryoablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral nasal-tissue cryoablation procedure (C9771).
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided by a chiropractor on November 29, 2022, 
billed with code 99203. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you have not been able to get a clear 
answer as to why this new patient visit is not covered by the Plan. The Plan denied your request. The Plan says 
that Medicare does not cover office visits from chiropractors as this is not manual manipulation of the spine. 
 
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 Plan has not addressed coverage under the supplemental chiropractic benefit 
in this case. The rationale is solely that Medicare does not cover office visits from a chiropractor. While this 
coverage exclusion is correct, the language of the contract does not make it clear that the same exclusion would 
apply to the supplemental benefit. It is noted that you were referred to this provider by Optum Health which the 
contract notes is the administrator for the supplemental chiropractic benefit. The Plan did not provide any full 
benefit documents for this supplemental benefit, so there is no evidence to support that an office visit cannot be 
covered by this benefit. We find that denial of payment of the services provided on this date is not 
substantiated. Therefore, we decided that the Plan has to pay for the office visit provided by a chiropractor on 
November 29, 2022, billed with code 99203.  
 
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.