Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. You say that the records provided support that 
revascularization is medically necessary. The Plan denied your request. The Plan says that the notes do not 
show that the enrollee has severe disease or symptoms that interfere with the ability to do daily tasks. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 revascularization services. Our 
reviewer says that revascularization services are considered medically reasonable and necessary in this case. 
Our physician reviewer found there is satisfactory documentation that the patient may have limb threatening 
ischemia. There is documentation that the enrollee is having both lifestyle limiting claudication as well as rest 
pain. Rest pain is a symptom of limb threatening ischemia. The enrollees ABIs are markedly decreased at 0.32 
on the right and 0.35 on the left. These ABIs are consistent with limb threatening ischemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization services have been met. Therefore, we decided that the Plan 
has to pre-approve revascularization services.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Ossur Rheo Knee (L5828 + L5845 + L5848 + L5856 +L5850). 
 
You asked the Plan to pre-approve an Ossur Rheo Knee. You say that the items are medically necessary. The 
Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 an Ossur Rheo Knee. Our reviewer says 
that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer 
found clinical documentation states that patient requires ambulation over long/unlimited community distances 
at different cadences, speeds and surfaces which would meet LCD criteria for a microprocessor knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Ossur Rheo Knee. have been met. Therefore, we decided that the Plan has to 
pre-approve an Ossur Rheo Knee (L5828 + L5845 + L5848 + L5856 +L5850).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair (49560) provided on July 13, 2021. 
  You asked the Plan to pay for the hernia repair (49560). You say that the medical records show the hernia 
repair was done and the gallbladder was removed due to stones. You say that the records should be reviewed as 
they clearly state two procedures were performed. The Plan denied your request. The Plan says CPT code 
49560 is included in CPT code 47562 and cannot be separately reimbursed. 
 
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 49560 
is a column II code to column I code 47562. CPT code 49560 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 the hernia repair (49560) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for an office visit. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
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 a $48 
copayment for Physician/Practitioner services, including doctors office visits-services received from all other 
specialists.  
 
You have been asked to pay a $48 copayment for an office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits-services received from all other specialists 
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 copayment for an office visit provided on 
January 5, 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 an LTACH specializes in recovery and 
their outcome scores demonstrate their level of success. You say that an LTACH level of care will optimize the 
level of recovery and prevent any unwarranted send back to the short-term acute care hospital. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that it is not safe for 
the enrollee to leave the hospital at this time because of continued decreased responsiveness. The Plan says that 
the enrollee is receiving the care needed in the hospital where they are currently and there is no need for 
transfer to an LTACH. 
 
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 more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more stable and 
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. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to an LTACH is not medically necessary at this 
time as the enrollee is not yet stable for discharge and as it would not be clinically advantageous. Completion 
of treatment at the current acute care hospital is recommended. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation (A0100) 
beyond the Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
your dialysis appointments. The Plan denied your request. The Plan says you have exhausted your routine 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. We reviewed the Plans trip report and verified that the Plan has covered 24 trips for routine transportation. Based on this information, we decided that 
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional trips for routine transportation (A0100) beyond the Plan's 
24-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total contact above knee addition (L5650) and the 
above knee alignable system (L5920). 
 
You asked the Plan to pre-approve the total contact above knee addition and the above knee alignable system. 
You say that the items are medically necessary. The Plan denied your request. The Plan says the total contact 
feature is included as a part of the preparatory prosthesis socket and a preparatory prosthesis is a non-alignable 
system because the changes that take place during the preparatory rehabilitation require follow-up. Therefore, 
an above knee alignable system 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the total contact above knee addition and the above knee alignable system have not been met. 
Specifically, you were approved for a left preparatory prosthesis which includes a total contact feature and is a 
non-alignable system.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve the total contact above knee addition (L5650) 
and the above knee alignable system (L5920).
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 clinical information provided supports the need 
for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee could receive care in another setting. 
 
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the services are not authorized because the provider and the facility are 
non-network providers who do not work with the member's health plan, and the member self-directed for care. 
The Plan also says that the member's primary care provider did not refer for services and the Plan requires 
authorization for certain services. 
 
 
 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 February 5, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on December 8, 2021. 
 
You asked the Plan to pay for an office visit. You say that you provided medical records for review. The Plan 
denied your request. The Plan says that the rendering provider is an OON provider. 
 
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. We requested the evidence of coverage (EOC) for the date of service and never 
received it. Therefore, we decided that the Plan has to pay for an office visit provided on December 8, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom backrest (E1399). 
 
You asked the Plan to pre-approve a custom backrest. You say that this equipment is medically necessary. The 
Plan denied your request. The Plan says the requested backrest is miscoded and there is no documented need 
for the requested custom molded backrest. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a comprehensive written evaluation by a 
licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which 
clearly explains why a prefabricated seating system is not sufficient to meet the beneficiarys seating and 
positioning needs. 
 
 
 
 
  
 
We looked at the file and Medicare rules. In this case, there is no documentation from the provider that 
explains why the prefabricated seating system would not be sufficient for the enrollees needs. Based on this 
information, we decided that Medicare rules for coverage of a custom backrest have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a custom backrest (E1399).
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 LTACH is the place your doctors and 
staff feel you need to be. The Plan denied your request. The Plan says the denial of authorization for LTACH 
care is correct. 
 
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 you require ongoing acute care services before transitioning to a lower level of care, 
and continue to receive acute care services that have not been denied. The record does not indicate that you 
require services at the LTACH that are not currently being received. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you received a below the knee leg amputation and 
are currently inpatient. You say that you cannot safely toilet, bathe, rest, or navigate in your new situation on 
your own, and have no assistance for these basic needs. You say that the lack of proper rehabilitation services 
prior to discharge would cause you life threatening accident or injury. You say that your life will be in jeopardy 
should you not receive the needed IRF services. The Plan denied your request. The Plan says the records do not 
show that the enrollee has daily intensive therapy needs. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a lower extremity wound and had a below the knee amputation. He was transferred to skilled 
nursing on June 8, 2022. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on September 23, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says the member's primary care physician did not refer for services. 
The health plan requires utilization of network providers when possible and available, and requires 
authorization for certain services. No medical necessity for an OON provider, such as an urgent or emergency 
situation, has been documented. 
 
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 Genetic Testing provided on September 23, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a L5-S1 Viadsic procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is insufficient high-quality evidence to support annulus 
fibrosus repair devices as an adjunct for discectomy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Viadisc 
procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a L5-S1 Viadsic procedure for the enrollee.