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. The Plan denied your request. The Plan says you do not require a 
coordinated interdisciplinary approach to rehab. 
 
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 physician reviewer found 
that you have no acute medical problems. You are medically stable and do not need a rehabilitation physician 
for close supervision 3 times per week for the ongoing management of any active or acute exacerbations of 
chronic medical conditions.  You do not need intensive therapies, consisting of at least 3 hours of therapy per day. Therefore, an IRF 
admission is not medically necessary based on medical stability and lack of medical complexity and lack of 
rehab nursing needs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a "Teeter" Table (E0941). 
 
You asked the Plan to pay for a Teeter" Table. You say that you need this item. The Plan denied your request. 
The Plan says this item is not medically necessary. 
 
  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a "Teeter" Table (E0941).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transport (A0426) and mileage (A0425), provided on 
November 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that the service was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the service was medically necessary. Our physician reviewer found the enrollee did require the expertise of 
trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport and 
could not have been provided by other means without endangering the enrollee's condition. A prudent 
layperson would believe that immediate medical attention was required for someone who appeared to be 
experiencing a heart attack, renal compromise and diabetic complications. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pay for the ambulance transport (A0426) and mileage (A0425), provided on November 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: 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 enrollee needs help completing daily tasks. The 
Plan denied your request. The Plan says the records do not support the ability to tolerate 3 hours of therapy per 
day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for progressive lower extremity weakness. He is at a 
maximal assist level for all mobility and lower extremity dressing. Physical and occupational therapy documents that he is at a lower assistance level than described in pre-
admission screening. He still needs assist for activities of daily living and mobility. The enrollee has no new or 
acute medical problems, is medically stable. He does not need a rehabilitation physician for close supervision 3 
times per week. He does not need intensive therapies, consisting of at least 3 hours of therapy per day. 
Therefore, an IRF admission is not medically necessary based on medical stability and lack of medical 
complexity and lack of rehab nursing needs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's doctor's notes do not show what type of pain they are having, they do not 
show how this affects their daily activities, they do not show a picture study of the enrollee's left hip, and the 
doctor's notes do not show why the enrollee needs this surgery. 
 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 physician reviewer 
found detailed documentation is not evident regarding advanced joint disease as evidenced by imaging, pain or 
functional disability attributable to the advanced joint disease, or unsuccessful non-surgical medical 
management, when appropriate, and attempted for a minimum of 3 months. The x-rays were noted to show 
mild-to-moderate degenerative arthritis. There is also plausible pathology of the lumbar spine that could be 
contributing to the symptoms. Detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures directed to the left hip for 3-months. 
The x-rays noted do not demonstrate malignancy of the joint involving the bones or soft tissues of the pelvis or 
proximal femur, avascular necrosis (osteonecrosis of the femoral head), fracture of the femoral neck, acetabular 
fracture, non-union or failure of previous hip fracture surgery, or malunion of acetabular or proximal femur 
fracture. Therefore, the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip 
arthroplasty), with or without autograft or allograft (CPT code 27130).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no evidence that the patient will be able to actively participate 
in physical and occupational therapy for a total of three hours per day. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care 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 that you have a past medical history of stroke, epilepsy, and a below the knee 
amputation in 2021 and are living at home with difficulty ambulating. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. In conclusion, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on June 28, 2021. 
 
You asked the Plan to pay for the ER visit. You say that you are billing emergency room provider services 
which have specific criteria in order to bill appropriately. You say that the claim should be processed 
appropriately based on the documentation provided which adequately supports the level billed. The Plan denied 
your request. The Plan says the billed service has been denied as it was reported with one or more diagnosis 
code pairs that are subject to an Excludes1 note. 
 
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 the ER visit is not supported in the medical record. Specifically, diagnosis codes R0609 and J9611 
cannot be billed together. Based on this information, we decided that Medicare rules for coverage of the ER 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the ER visit provided on 
June 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on April 25, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not under hospice for the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on April 25, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. You say that this drug is medically reasonable and necessary The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Trivisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, the patient 
has not tried and failed the required drug(s). There is no documentation provided indicating that the plans 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on April 23, 2021. 
 You asked the Plan to pay for therapeutic activities. You say that the provided records substantiate the service 
at issue. The Plan denied your request. The Plan says rules for payment have not been met because the service 
at issue is included in another billed code. 
 
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 97530 
is a column II code to column I code 92526. This claim 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 therapeutic activities (97530) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services (CPT code(s): G0402 and G0463) 
provided on August 30, 2021. 
 
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 office services have not been met. Multiple medical visits on 
the same day were reported with the same revenue center for HCPCS codes G0402 and G0463 and condition 
code G0 was not reported to specify that multiple medical visits occurred on the same day with the same 
revenue center, and that these visits were distinct and constituted independent visits. Therefore, we find the 
Medicare rule for payment of this August 30, 2021, claim has not been met and could not be processed for 
payment. Therefore, we decided that the Plan does not have to pay for the office services (CPT code(s): G0402 
and G0463) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiopulmonary resuscitation (CPT code 92950) provided 
on July 13, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service was previously approved/paid. The Plan states there is no additional documentation 
supporting an additional service which was billed and remains denied. 
 
  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 code 92950 is not supported in the medical record. The member had cardiopulmonary 
resuscitation on July 13, 2021. One (1) unit of 92950 was previously approved/paid. There is no documentation 
supporting an additional service which was billed and remains denied. 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 pay for cardiopulmonary resuscitation (CPT code 92950) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of 
intraoral x-rays (D0210), and prophylaxis (D1110) provided on October 26, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. 
You say that you have been using the same dental facility for dental care for many years and have never been 
denied coverage for dental cleanings and x-rays. You also say that you are retired and on a fixed income with 
limited finances. The Plan denied your request. The Plan says services rendered by a provider who is not in-
network are not covered by the Plan. 

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on 
October 26, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Synvisc. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Orthovisc OR Supartz FX before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).