Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that a semi-electric hospital bed is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested semi-electric hospital bed is not medically reasonable and necessary. Our 
physician reviewer found that despite provided medical records that report weakness and needs for assistance 
with mobility, transfers and activities of daily living, the provided records do not document that the patient 
requires position of the body in ways not feasible in an ordinary bed. In addition, the provided records do not 
document the need for frequent changes in body position or immediate changes in body position. The criteria 
for a semi-electric hospital bed have not been satisfied at this time. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special group 3 power wheelchair and accessories 
(K0849, E0973, E2363, E1028). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessorizes are medically necessary. The Plan denied your request. The Plan says the requested power 
wheelchair is not reasonable and necessary. A request for a wheelchair that meets your needs and Medicare 
rules can be reviewed if submitted. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
inconsistent documentation that you have a personal mobility deficit that impairs participation in mobility 
related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within 
the home. There is inconsistent documentation that your mobility deficit can or cannot be helped by the use of 
a walker, cane or manual wheelchair. A medical visit note from 04/29/2022 reports you have a severe mobility 
deficit; another evaluation of 07/19/2022 reports that you can ambulate 500 feet without difficulty with a 
rollator. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a special group 3 power wheelchair and accessories (K0849, E0973, 
E2363, E1028).
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 it is felt that IRF care is needed. The Plan denied 
your request. The Plan says IRF criteria have 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for abdominal pain and urinary tract infection. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical record supports a need for physical 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two units of code 64636 reported for lumbar facet joint 
denervation provided on January 27, 2022. 
 
You asked the Plan to pay for the two units of code 64636. You say that this was billed correctly based on the 
number of nerves treated. The Plan denied your request. The Plan says only two facet joints were treated 
meaning that the additional unit of 64636 is not supported. A corrected claim with a single unit could be 
considered if submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 two units of code 64636 Our reviewer 
says that the reported two units of the code at issue are not supported in the record. Our physician reviewer 
found that per the current CPT Professional edition code book, 64635, and 64636 are reported per joint, not per 
nerve.  Although two nerves innervate each facet joint, only one unit per code may be reported for each joint 
denervated, regardless of the number of nerves treated. For each initial, single level thermal radiofrequency 
destruction performed with image guidance, code 64635 is used, and each unit of 64636 represents one 
additional joint. In this case, only two joints were treated, L3-L4 and L4-L5. As such, an additional unit of 
64636 is not supported. 
 
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 two units of code 64636 have not been met. Therefore, we decided that the 
Plan does not have to pay for the two units of code 64636 reported for lumbar facet joint denervation provided 
on January 27, 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 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee is 
tolerating her current therapy. The enrollee can complete her current treatment before transitioning to a lower 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic medical services provided on 
June 10, 2022. 
 
You asked the Plan to waive the copayment for diagnostic medical services. You say that you cannot afford 
this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $375 
copayment for outpatient diagnostic medical services.  
 
You have been asked to pay a $375 copayment for diagnostic medical services. Diagnostic medical services 
fall within the outpatient diagnostic medical services 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 diagnostic medical services provided on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urine PCR testing (87481, 87491, 87496, 87500, 87511, 
87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661,87798) provided on November 9, 2021. 
 
You asked the Plan to pre-approve urine PCR testing. You say that services were medically necessary. The 
Plan denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and 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 urine PCR testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the 99-year-old enrollee was diagnosed with urethral syndrome and urgency of 
urination. Urinary Tract Infection panel, including antibiotic resistance markers utilizing PCR testing of the 
urine, was performed on November 9, 2021. The requesting provider and the performing laboratory were both 
out-of-Network with the Health Plan. The Health Plan must follow CMS rules and guidance per NCD 190.12. 
The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. 
The PCR testing is considered unproven and 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve urine PCR testing (87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 
87640, 87641, 87651, 87653, 87661,87798) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the F1CDx genetic testing services provided on March 3, 
2022. 
 
You asked the Plan to pay for the F1CDx genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment cannot be made 
for these services as required billing information is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must include the unique test identifier 
on the claim for the molecular testing. Based on this information, we decided that Medicare rules for coverage of the F1CDx genetic testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the F1CDx genetic testing services provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment purchased on March 3, 2022, 
from a provider not certified with Medicare. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment cannot be made 
for the services provided by a supplier not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
purchased on March 3, 2022, from a provider not certified with Medicare.
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 you are unable to care for yourself at home. You say 
you need rehabilitation to gain your strength in order to return home. The Plan denied your request. The Plan 
says the SNF care is not medically necessary. 
 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 there are no identifiable skilled nursing service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. You do not require skilled nursing or therapy services daily. The records do not show a significant 
decline in your functional status compared to your recent baseline to necessitate daily inpatient skilled therapy 
services. As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. Based on the medical records provided you do not require the services 
on an inpatient basis, only in a skilled nursing facility setting.  
 
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 six physical therapy visits of the requested twelve visits 
to be provided by a network provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the physical therapy is medically 
necessary. The Plan denied your request. The Plan says the physical therapy visits are 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 pre-approve the physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the record shows there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the patient's condition. Based 
on the available records the patient appears to have improved with therapy to the point of being able to manage 
standing, walking, bending and vacationing. records do not support that the complexity of the enrollee's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
patient's symptoms or functional status. Based on the medical records provided there is no documentation that 
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The 
record shows the enrollee appears to have improved with therapy to the point of being able to manage standing, 
walking, bending and vacationing. Based on the medical records provided, there is no documentation that the 
specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver 
a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The record 
indicates the enrollee wants to gain strength and repetitive exercise does not require the expertise of a 
professional skilled physical therapist.  
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six physical therapy visits of the requested twelve visits to be provided by a 
network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 you do not require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial to continue SNF care. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to increase your strength and endurance so 
you can have the mobility to go home. The Plan denied your request. The Plan says admission to IRF was 
denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
 
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 were admitted for respiratory failure and congestive heart failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.