Persius/hicric huggingface dataset:
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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support the necessity for admission to an IRF. The 
enrollee's rehabilitation needs can be met safely at a lower intensity and alternate setting such as in a skilled 
nursing 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 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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Despite almost four 
weeks of intensive therapy in the rehabilitation facility, her functional level remains minimally (if at all) 
objectively improved; she remains non-ambulatory and moderate to maximum assist for transfers. The enrollee 
does not require the services on an inpatient basis, or in a skilled nursing facility setting. Services in a long-
term care facility on a part time basis appear appropriate in this case. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment for teeth 2, 29, 31, 10, 11, 12, 13, 14, 
18, 19 and 20 (D6057) and abutment supported porcelain/ceramic crown for teeth 2, 29, 31, 10, 11, 12, 13, 14, 
18, 19 and 20 (D6058). 
 
You asked the Plan to pre-approve custom abutment for teeth 2, 29, 31, 10, 11, 12, 13, 14, 18, 19 and 20 and 
abutment supported porcelain/ceramic crown for teeth 2, 29, 31, 10, 11, 12, 13, 14, 18, 19 and 20. You say that 
the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom abutment for teeth 2, 29, 31, 10, 11, 12, 13, 14, 18, 19 and 20 (D6057) and abutment supported 
porcelain/ceramic crown for teeth 2, 29, 31, 10, 11, 12, 13, 14, 18, 19 and 20 (D6058).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you regularly comply with all administrative 
requirements for payments. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 laboratory services provided on November 5, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Chest Wall Oscillation Afflovest 
provided on September 19, 2021. 
 
You asked the Plan to waive the coinsurance for the Chest Wall Oscillation Afflovest. You said that you were 
not told at the time of delivery that it was a rental. The Plan denied your request. The Plan says the coinsurance 
charged is correct. 
 
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 20% 
coinsurance for durable medical equipment that is Medicare-covered with a total rental or purchase price of 
$350.01 or more of the Medicare allowable rate per item.  
 
 
 
 You have been asked to pay $222.76, which is 20% of the allowed amount ($1,113.80), for the Chest Wall 
Oscillation Afflovest. A Chest Wall Oscillation Afflovest falls within the Durable medical equipment (DME) 
and related supplies 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 coinsurance for the Chest Wall 
Oscillation Afflovest provided on September 19, 2021.  
Your complaint about the slow responsiveness of the plan and your issues with returning your equipment is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99601) provided April 30, 2021. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is ineligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "I" and is invalid for Medicare payment. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99601) provided April 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health physical therapy visits. 
 
You asked the Plan to pre-approve 10 home health physical therapy visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 10 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do 
not show that skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. Home exercises completed independently should 
suffice for this enrollee based on the provided 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 10 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stent surgery for major artery endovascular 
revascularization with angioplasty. 
 
You asked the Plan to pre-approve the requested surgery. You say that the patient is experiencing extreme pain 
and urgently needs this service. The Plan denied your request. The Plan says the requested procedure 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 pre-approve the requested surgery. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found The patient has had symptoms of claudication from time to time, but guidelines for this 
procedure are not met. In summary, there is insufficient documentation to support the medical necessity for 
peripheral artery angioplasty 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 requested surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stent surgery for major artery endovascular revascularization with angioplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination (71045) provided on August 5, 
2021. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the Radiologic examination (71045) 
provided on August 5, 2021 have been met. Therefore, we decided that the Plan does not have to pay for the 
Radiologic examination (71045) provided on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 22, 2021. 
 
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 Current Procedural Terminology (CPT) code 63030-59 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report describes laminectomy, diskectomy and foraminotomy procedures performed on L1 - L2 
level. The documentation does not support a single laminectomy performed at a different level, and therefore 
CPT 63047 Laminectomy, facetectomy and foraminotomy (unilater or bilateral with decompression of spinal 
cord, cauda equina and/or ner root(s), (eg, spinal or lateral recess stenosis), single vertebral segment;  lumbar 
includes a laminectomy with decompression, and would not be separately reported. 
 
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 pay for surgical services provided to the enrollee on May 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Naratriptan Tabs (2.5mg). 
 
You asked the Plan to pre-approve Naratriptan Tabs. You say that the patient has tried and failed other drugs 
and has had success with this drug previously. The Plan denied your request. The Plan says this drug is not 
covered under the patient's medical benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Naratriptan Tabs (2.5mg).  
 
Benefits for Naratriptan Tabs may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (87633) 
provided on May 28, 2020. 
 
You asked the Plan to pay for code 87633. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid 
(87633) provided on May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76705) provided November 1, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another billed code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
has a bundled relationship with code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services (76705) provided November 1, 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 this is medically necessary. The Plan 
denied your request. The Plan says LTACH care is not medically reasonable and 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 still somewhat unstable and requires short-term additional 
acute care services that can safely be administered at the current facility until a more appropriate level of care is 
determined. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous and as the 
enrollee does not have a stable feeding source. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87486, 87581, 87631) provided July 8, 
2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services (87798, 87486, 87581, 87631) 
provided July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services from March 14, 2022 
onward. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says your condition has improved, and 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.  
 
 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 admission is not medically reasonable or necessary. Our physician reviewer found 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 did 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. The 
health plans denial of continued inpatient psychiatric services is appropriate. 
 
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 inpatient mental health services from March 14, 2022 onward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that a lower level of care will 
result in readmission. The Plan denied your request. The Plan says you do not require additional inpatient 
psychiatric days. You are stable and can step down to a lower level of care. 
 
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 continued inpatient psychiatric care. Our reviewer says that additional inpatient psychiatric care days are not medically necessary. Our physician 
reviewer found that it is not expected that you would improve in a reasonable period of time beyond the dates 
in question as you are not showing any dangerousness to self or others, auditory or visual hallucinations and 
you are without aggressive behaviors while not showing any acute threats of safety. You are cooperative and 
compliant with medication. It did 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 
do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The 
health plans denial of continued inpatient psychiatric services appears appropriate. It does not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve your condition 
or for the purpose of diagnosis.  
 
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 inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care.