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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate level of 
care for this enrollee. You say the enrollee is medically stable to be transferred to the LTACH level of care at 
this time. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 87798 billed for date of service March 8, 2022.

You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that these services were reported correctly. The Plan denied your request. The Plan says these services are not supported for separate payment.

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 codes 87653 and 87481 are column II to both 87150 and 87801. These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for codes 87653 and 87481. In addition, we have confirmed that codes 87798 and 87641 are both column II codes to both 87150 and 87801, and code 87150 is a column II code to column I code 87500; however, codes 87150, 87641 and 87798 were billed with a modifier.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for procedure codes 87150, 87641, and 87798. Our reviewer says that the use of the 91 modifier is not supported for these services. Our reviewer found the documentation does not support that these were separate procedures which would not be included in the primary services.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 87798 billed for date of service March 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a right 
reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation you will require a greater 
than 2 midnight 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that you are approved for a right reverse total shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 87798 
billed for date of service March 8, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that these 
services were reported correctly. The Plan denied your request. The Plan says these services are not supported 
for separate payment. 
 
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 codes 87653 and 87481 are column II to both 87150 and 87801. These 
services have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met for codes 87653 and 87481. In addition, we have confirmed that 
codes 87798 and 87641 are both column II codes to both 87150 and 87801, and code 87150 is a column II code 
to column I code 87500; however, codes 87150, 87641 and 87798 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87641, and 87798. Our reviewer 
says that the use of the 91 modifier is not supported for these services. Our reviewer found the documentation 
does not support that these were separate procedures which would not be included in the primary services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653 and 
87798 billed for date of service March 8, 2022.
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 enrollee needs to be admitted to the SNF for 
continued treatment, rehab, and therapy for strength building to return home. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for admission to a SNF. 
 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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and long-term, can be provided at 
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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
 
 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 Euflexxa. Our reviewer says that the 
enrollee does not meet the coverage criteria for Euflexxa. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E0955, 
E1007, E1012, E1028x2, E2311, E2313, E2361, E2377, E2620, E2624, K0040x2). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple 
power options included with K0861, power wheelchair. The electronic connection, expandable controller and 
harness cannot be covered as it is not medically necessary to control the three requested power options through 
the joystick. As the power wheelchair with multiple power options is not reasonable and necessary, none of the 
requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
advanced age, kyphosis, dementia, and a history of polio. He has recurrent falls and upper extremity weakness. 
The enrollee can stand pivot transfer and toilet independently. He has dementia but no mental status exam is 
reported. No history pressure sores. The enrollee's mental status is not measured. It is not clear he can safely 
use a power wheelchair. The power tilt and recline system and associated accessories exceed the enrollee's 
needs. There is no high risk for skin breakdown, no spasticity, or intermittent catheter. 
 
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 power wheelchair (K0861) and accessories (E0955, E1007, E1012, 
E1028x2, E2311, E2313, E2361, E2377, E2620, E2624, K0040x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 heavy-duty, multiple 
power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862) and accessories 
(E1002, E1012, E2311). 
 
 
 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is unable to 
get herself all the way back in her wheelchair and unable to reposition in the wheelchair without the use of tilt 
in space. The enrollee meets criteria for tilt as she is unable to perform functional weight shift. 
 The Plan denied your request. The Plan says the requirement for a group 3 power wheelchair (PWC) is 
meeting criteria for a multi-power option group 2 PWC. Overall, the enrollee does not meet guidelines for a 
group 2 multi-power option PWC therefore, does not meet criteria for a group 3 PWC. 
 
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 provided records 
document that the enrollee has 4 out of 5 upper extremity strength and is independent with feeding (with Meals 
on Wheels) thus indicating she has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. Provided records do not support that the enrollee is high risk for skin 
breakdown (she is able to walk up to 20 feet with a cane or walker), has a history of pressure ulcer(s) or has 
had skin flap surgery (records report an "open area" on her right lower extremity but records do not clarify that 
this is a pressure ulcer). Records do not document she performs bladder self-catheterization and is unable to 
transfer independently or that she has increased muscle tone or spasticity. Thus, the multiple power option base 
and power tilt are not supported. The enrollee may qualify for a simpler power wheelchair. 
 
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 power wheelchair, group 3 heavy-duty, multiple power option, 
sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0862) and accessories (E1002, E1012, 
E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission stating the enrollee's needs and care cannot be met at a lower level of care. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. You say that there is far less radiation exposure to 
non-target normal tissue with proton therapy. The Plan denied your request. The Plan says the request 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 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 there is insufficient prospective, long-term clinical data available to determine whether or 
not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam 
radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and 
efficacy. Recent data shows no significant differences in late patient-reported toxicity outcomes between 
proton beam therapy and IMRT. The most recent guidelines state that PBRT offers no clinical advantage over 
other forms of definitive treatment. According to guidelines, proton beam therapy may be offered to individuals 
enrolled in an approved prospective clinical trial or multi-institutional registry. Therefore, Proton beam 
radiation therapy is not medically reasonable and necessary in this case. 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 proton beam radiation therapy (PBRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device. 
 
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the insertion of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is a lack of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 insertion of a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left gonadal vein embolization. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has significant pelvic and 
thigh pain extending to her legs. The Plan denied your request. The Plan says the enrollee has not failed 
pharmacotherapy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has other specified conditions associated with female genital organs and 
menstrual cycle. The enrollee reported significant pelvic and thigh pain and heaviness extending to her legs. 
A left gonadal venogram demonstrated that the left gonadal vein is dilated with large collaterals extending to 
the pelvis. The ovarian vein diameter is not documented. There is no single approach for the treatment of pelvic 
congestion syndrome, and the optimal therapy has not been determined. The case file does not contain 
documentation of trial and failure of medical management. Further study is needed to address long-term 
outcomes, and to determine which treatment regimens are indicated for the management of specific clinical 
scenarios. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left gonadal vein embolization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital admission. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital admission. You say that the services are 
necessary. The Plan denied your request. The Plan says the correctional health department is responsible for the 
cost of healthcare since the enrollee is currently incarcerated. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient psychiatric hospital admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient psychiatric hospital admission.