Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor must document that they agree with the admission. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. 
The enrollee may benefit from additional physical and occupational therapy but the documentation does not 
reveal that this therapy must be only on an intensive level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine and 
other perfusionist services provided on August 25, 2021. 
 
You asked the Plan to pay for the perfusionist services. You say that the perfusionist should be paid for the 
services rendered. The Plan denied your request. The Plan says these services are included in payment made to 
the facility. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The 
rules also indicate that in order to bill Medicare and receive payment, a provider must be enrolled in the 
Medicare program. 
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation 
of a heart/lung machine and other perfusionist services provided on August 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulator system for treatment of central sleep 
apnea (0424T). 
 
You asked the Plan to pre-approve a neurostimulator system for treatment of central sleep apnea. You say that 
this is medically reasonable and necessary. The Plan denied your request. The Plan says the published literature 
does not support the medical necessity for transvenous phrenic nerve stimulation for central sleep apnea. 
 
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 a neurostimulator system for treatment 
of central sleep apnea. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the reviewed documentation indicates 
that the enrollee has central sleep apnea (CSA). Overall, limitations in the published data on the use of phrenic 
nerve stimulation to treat CSA include studies based on a mixed population of positive airway pressure (PAP)-
treated and PAP-naive patients, a lack of comparison with the current standard of care and lack of data on long-
term cardiovascular outcomes and impact on survival.  
 The evidence is insufficient to determine the effects of the technology on health outcomes. The review has 
determined that the items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a neurostimulator system for treatment of central sleep apnea have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator system for treatment 
of central sleep apnea (0424T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve standard - weight frame motorized/power wheelchair 
with programmable control parameters for speed adjustment, tremor dampening, acceleration control and 
braking (Current Procedural Terminology (CPT) code K0011). 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee was was denied an electric 
wheelchair, but Numotion was asking for an electric scooter. The Plan denied your request. The Plan says the 
enrollee's records do not show the enrollee needs a power wheelchair to complete mobility-related activities of 
daily living (MRADLs) in their home; the enrollee is unable to use a cane, walker, manual wheelchair or 
scooter to complete their MRADLs in your home; the enrollee is able to safely use a power wheelchair; and a 
home evaluation showing a power wheelchair will fit in their home. The Plan states in addition to clinical 
records from the enrollee's provider showing the required information, the Plan also needs to receive a standard 
written order (SWO) from the enrollee's provider for the power wheelchair.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
[state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical 
item."] Our physician reviewer found the documentation does not reveal that the enrollee has a personal 
mobility deficit that impairs their participation in mobility related activities of daily living (MRADLs) such as 
toileting, feeding, grooming and bathing in customary locations within the home. The documentation does not 
reveal that the enrollee is unable to use a walker, cane, or manual wheelchair and that the patient can safely 
operate a power mobility device. The documentation does not reveal a home assessment indicating that the 
requested power mobility device can safely maneuver in the home and will improve MRADL participation. 
The criteria for a power wheelchair or power scooter have not been met per the NCD. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve standard - weight frame motorized/power wheelchair with programmable control 
parameters for speed adjustment, tremor dampening, acceleration control and braking (Current Procedural 
Terminology (CPT) code K0011).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography (77065) provided on August 
18, 2021. 
 
You asked the Plan to pay for the diagnostic mammography. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the billed service exceeds the 
MUE.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic mammography have not been met. Therefore, we decided that the Plan does not have to pay for the 
diagnostic mammography (77065) provided on August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to continue SNF services to get better. 
The Plan denied your request. The Plan says that you no longer require skilled services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on May 19, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the services were rendered based on the 
patient condition and the level of service was coded appropriately. The Plan denied your request. The Plan says 
payment for CPT code 99100 is always bundled into payment for other services. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, multi-axial rotation unit 
('mcp' or equal) (CPT code L5986) and all lower extremity prosthesis, shank foot system with vertical loading 
pylon (CPT code L5987). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the records we have do not show why the requested advanced foot is needed. The Plan 
states the request for K3 foot and ankle does not meet Medicare criteria as reasonable and necessary. The Plan 
states a request for K2 foot that meets the member's needs and Medicare guidelines can be reviewed if 
submitted. 
 
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 items. Our physician reviewer 
found the documentation indicates the member uses a cane and a powered wheelchair for mobility which does 
not support that they are a K3 ambulator. The requested K3 foot and ankle 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve all lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) (CPT code L5986) and 
all lower extremity prosthesis, shank foot system with vertical loading pylon (CPT code L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15-minutes (97810) acupuncture, each 
additional 15 minutes (97811) provided October 27, 2021 to November 3, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that please review all documentation included 
in this request and kindly approve your services for payment, as these services were medically necessary. The 
Plan denied your request. The Plan says the services was rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were rendered by a licensed 
acupuncturist, not a physician. The health Plan contract specifically says that the service must be provided by a 
legally qualified physician practicing within the scope of their license. Therefore, we decided that the Plan does 
not have to pay for acupuncture, initial 15-minutes (97810) acupuncture, each additional 15 minutes (97811) 
provided October 27, 2021 to November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 26, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you went to the dentist to have an extraction. 
You say that you would not do it because you did not have someone to take you home. You also say that the 
service that you expected was not delivered so you should not be billed. The Plan denied your request. The 
Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 
been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on May 10, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on October 26, 2021.
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 you do not have a need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You are walking household 
distances with contact guard assistance and is contact guard assist for transfers. You do not require the services 
on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on September 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the anesthesia. You say that the facility is required to obtain authorization and 
service provided to the enrollee should be on the same claim as the facilities claim. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no approved 
authorization. Also, the service rendered by the provider was not urgent or emergent. 
 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 anesthesia provided on September 29, 2021, by an 
out-of-network (OON) provider.
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 you do not have a need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You are walking greater than 
household distances with contact guard assistance and is stand-by assist for transfers. You do not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility with part time therapy services 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 pay for the comprehensive oral exam (D0150) provided on August 
30, 2021. 
 
You asked the Plan to pay for the comprehensive exam. You say that you needed to see a new provider for this 
appointment, and they required this exam to be completed. The Plan denied your request. The Plan says you 
had a previous comprehensive oral exam in January 2021, which was covered by the Plan at that time. This 
service may only be covered once every 36 months, and therefore the comprehensive exam on the date in 
question is denied. The Plan also addresses your provider quality of services concerns in a separate case. 
 
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. The Plan can cover one 
comprehensive oral exam every 36 months. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested 
in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral exam (D0150) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive eye examination provided on December 4, 
2020. 
 
You asked the Plan to pay for the comprehensive eye examination. The Plan denied your request. 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 Plan says that the Plan has 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 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 a comprehensive eye examination provided on December 4, 
2020.