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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are trying to get into acute rehabilitation for your 
lungs to breathe and currently on oxygen needing supplemental oxygen to do any activity such as walking. The 
Plan denied your request. The Plan says your criteria was not met for acute rehabilitation, care you require can 
be rendered in an alternate setting, a home with or without homecare or outpatient services. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87481, 87640, 87653, 87150, 87500, 87798) 
provided on December 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services were not reported in 
accordance with Medicare billing guidelines. 
 
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. Specifically, the Plan has not cited the rule used to make their decision and we 
were unable to find this information in a determination which applies to the state where these services were 
provided. In addition, the services at issue were each reported with the -59 modifier, indicating that they were 
provided as separate and distinct services. It does not appear that the Plan has performed a review to determine 
whether the reported modifiers were appropriate or not. The Plan has not fully substantiated their denial in this 
case. Therefore, we decided that the Plan has to pay for laboratory services (87481, 87640, 87653, 87150, 
87500, 87798) provided on December 22, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Kit. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 Kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 Kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for pontic - porcelain/ceramic (D6245) provided on 
November 18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not understand how the services 
are not covered, because you pay your monthly premium. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. 
 
The allowed amount of the covered dental service total $754, resulting in a coinsurance amount of $377 and 
Plan payment amount of $377. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment.  
 
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 pay more for pontic - porcelain/ceramic (D6245) provided on November 
18, 2022.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for admission to an 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 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retainer crowns (D6740) for tooth #6 and #7. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot do a partial and the request 
services are medically necessary. The Plan denied your request. The Plan says your benefit for the requested 
items or services has already been exhausted. 
 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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of approval of April 6, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the retainer crowns (D6740) for tooth #6 and 
#7.
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 LTACH is medically necessary for the 
enrollee's care and meets the criteria for placement. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 record indicates that the enrollee is improving but has ongoing acute medical 
issues that still require acute care services 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 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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy. 
 
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 enrollee was admitted for a crush injury of the hand. The enrollee's medical 
problems are stable, and 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 medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation 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 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 procedure codes 95937, 95886, and 95909 provided on 
November 24, 2021. 
 
You asked the Plan to pay for procedure codes 95937, 95886, and 95909. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation does not support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  

We find that CPT codes 95937, 95886, and 95909 are not supported in the medical record. Specifically, the 
technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, paired 
stimuli) for each nerve, by any 1 method; therefore, code 95937 cannot be verified. 
 
The technical report did not include documentation of a complete needle electromyography, per each extremity 
with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity 
study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies, for 5-6 studies; therefore, code 
95909 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95937, 95886, and 
95909 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95937, 
95886, and 95909 provided on November 24, 2021.
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 IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The enrollee's needs can be provided safely in other settings such as, skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has 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.
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 been in the hospital and you need 
rehabilitation. 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosela (trilaciclib) (J1448). 
 
You asked the Plan to pre-approve the drug. You say that the enrollee is high risk for neutropenia. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our physician reviewer found 
the requested use of Cosela is not FDA-approved for the enrollees diagnosis. It is approved for extensive stage disease and this enrollee has limited stage or localized small cell bladder cancer. Alternatives do exist for 
prevention of neutropenic fever. The use is not supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cosela (trilaciclib) (J1448).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that you do not want home healthcare 
services. You also say that you prefer to be inpatient at the hospital. The Plan denied your request. The Plan 
says you do not meet the requirements for an inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found you are undergoing a planned diagnostic laparoscopy. The documentation indicates 
that you are medically stable and have been provided medical clearance to undergo this elective procedure. The 
planned procedure is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. 
The reviewer also found that the procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
Therefore, the reviewer found that the requested inpatient admission 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 an inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not been evaluated by a spine surgeon. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has not had prior spine surgery. She has tried 
physical therapy, chiropractic therapy and has an epidural steroid injection. Her MRI shows multi-level spinal 
stenosis and degenerative changes. The enrollee does not have an approved indication for a spinal cord 
stimulator trial. She also has not had a surgical consultation. Therefore, the request is deemed not medically 
reasonable and necessary at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 7, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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.