Persius/hicric huggingface dataset:
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 need to be fully healed, and without this level of 
care you cannot go home. The Plan denied your request. The Plan says you do not meet all the requirements for 
an IRF 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E0955, E0960, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2613, E2622, K0040, K0108). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request for power wheelchair cannot be covered. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate a power tilt or recline. 
 
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 a group 3 power wheelchair and accessories (K0861, E0955, E0960, E1007, E1012, 
E1028, E2311, E2313, E2361, E2377, E2613, E2622, K0040, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has a diagnosis of COPD, although there are no pulmonary function tests to confirm 
severity. The enrollee has had 2 recent admissions for respiratory failure. Arterial blood gas studies (ABGs) 
during the most recent admission are consistent with mild chronic hypercarbic respiratory failure. The enrollee 
may benefit from BiPAP with average volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ExciteOSA device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have mild obstructive sleep apnea, and are having difficult with continuous positive airway 
pressure (CPAP). Your sleep physician has ordered ExciteOSA. This device is considered investigational 
because there is inadequate clinical data supporting its effectiveness. It is not currently covered by Medicare. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the ExciteOSA device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery provided on November 23, 2022. 
 
You asked the Plan to pay for eye surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for eye surgery provided on 
November 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that network providers cannot provide in-home 
services. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99213-25) provided on October 19, 2022. 
 
You asked the Plan to pay for the office visit. You say that the office visit billed was to treat additional 
diagnoses outside of those addressed during the procedure that took place on the same date of service. You also 
say that this should be reprocessed and paid. The Plan denied your request. The Plan says that the claim 
processed correctly. The Plan says that payment made for the surgery include the benefit for the pre-operative, 
post-operative, and same day visits. The Plan also says it includes the benefit for related procedures and 
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.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer found the medical records do 
support the use of evaluation and management code 99213 to be billed with a 25 modifier to separate the 
payment from 29581, also performed during this visit. The documentation supports the level of the evaluation 
and management as other diagnosis were discussed with this enrollee. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have been met. Therefore, we decided that the Plan has to pay 
for the office visit (99213-25) provided on October 19, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial for 
additional services. The Plan denied your request. The Plan says the services are not medically necessary. 
 
 
 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that you require additional skilled rehabilitation services. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health 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 you are currently in a skilled nursing facility and are 
being denied therapy services you need so you can go home. The Plan denied your request. The Plan says you 
do not meet the medical criteria for 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical and 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased 
from the out-of-network (OON) provider on August 4, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to issue reimbursement care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to issue reimbursement for these items. Therefore, we decided 
that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased from the out-of-
network (OON) provider on August 4, 2022.
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 due to the medical needs of the enrollee, the 
services are necessary to provide the appropriate level of care. The Plan denied your request. The Plan says the 
enrollee's needs can be met in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that enrollee has had clinical/functional status 
change, thus, an assessment by skilled nursing and therapy would be medically appropriate. However, no 
specific recommendation was given for frequency of skilled nursing assessment required, and the evaluating 
therapists recommend home with home health care. As such, there is no documentation to show that enrollee 
requires daily skilled services on an inpatient basis 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that you could not find a network provider that 
could perform the recommended treatment. The Plan denied your request. The Plan says network providers are 
available to render necessary care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast prosthesis (L8010). 
 
You asked the Plan to pre-approve the breast prosthesis. You say that the item is necessary. The Plan denied 
your request. The Plan says the item is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the breast prosthesis have not been met. The rules say that a 
mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the definition of a prosthesis. 
Therefore, we decided that the Plan does not have to pre-approve the breast prosthesis (L8010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the service. You say that the enrollee has been suffering from this 
debilitating disease for two years which has greatly impacted their daily living. You say that this minimally 
invasive procedure is the most appropriate treatment. The Plan denied your request. The Plan says this 
procedure has not been shown to be safe and effective. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex superion interspinous 
spacer at L4-5, in this case, is 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are necessary because you live alone 
and are at risk of falling, have a bit of delirium, need to gain strength to walk and need help making meals and 
bathing. The Plan denied your request. The Plan says your condition does not meet the requirements for 
coverage of SNF 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 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 clinical documentation shows that you have had clinical/functional status 
change thus assessment by skilled nursing and therapy would be medically appropriate. There is no 
recommendation given for frequency of skilled nursing required and skilled therapy/team recommend 
intermittent skilled therapy thus there is no documentation to show you require daily skilled services on an 
inpatient basis 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from August 16, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for the therapy services. You say that you were referred to physical therapy and it 
was medically necessary. The Plan denied your request. The Plan says that the additional physical therapy was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you were receiving repetitive exercise. In the documentation 
provided no goals were defined, no objective evidence of response to therapy, and no indication based on prior 
response what the indication was for continued therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for physical therapy services provided from August 16, 2022, to September 16, 2022.