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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found you were admitted to the hospital 
for weakness and falls. You are now medically stable with 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 the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
August 25, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the continued services are 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 
continued services are not medically necessary. Our physician reviewer found the enrollee has no skilled 
nursing needs. She has skilled therapy needs but doe snot require skilled therapy on a daily basis. Although 
records document that she is very limited functionally, the records do not document a significant improvement 
in the enrollee's functional status with daily inpatient treatment for two week to necessitate further daily 
inpatient skilled therapy services. As a practical matter, the enrollee does not require the necessary services on 
an inpatient basis at the SNF 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 continued skilled nursing facility (SNF) care beyond August 25, 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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 lumbar spinal surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage IV rectal cancer 
that is not deficient mismatch repair, microsatellite instability-high or TMB-H. The Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. Keytruda is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
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 the enrollee would benefit from short term 
rehabilitation to improve functional mobility, assisted daily living, energy conservation, and gait to prevent 
acute care hospital readmission and reduce caregiver burden for safe discharge home. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an inpatient 
rehabilitation facility. 
 
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 pelvic fracture after a fall. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has 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 IRF admission and 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He has not had 
a significant change in his baseline medical conditions and does not require the intensity of rehabilitation 
physician oversight provided in the acute inpatient rehabilitation setting. He does not require rehabilitation 
nursing for complex wound care, tracheostomy management or bowel and bladder management. His medical 
and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. The enrollee does not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. A physical and occupational therapy progress note dated 
9/8/2022 indicated that the enrollee was contact guard assist for bed mobility and transfers and ambulating 70 
feet with a walker x 3 with rest breaks. Motor strength was noted to be 3+ to 4/5 in the lower extremities. He 
required minimal assistance for toilet transfers. The enrollee has had a decline in his baseline level of function, 
but he does not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 pre-approve the rental of an oxygen concentrator and portable 
oxygen. 
 
You asked the Plan to pre-approve the rental of an oxygen concentrator and portable oxygen. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 rental of an oxygen concentrator 
and portable oxygen Our reviewer says that the documentation does not support that the requested items are 
medically reasonable or necessary. Our physician reviewer found you have a past medical history of chronic 
obstructive pulmonary disease. The provided records do not document that you have hypoxemia. This means 
there is no documentation to support that you meet criteria for home oxygen therapy. 
 
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 rental of an oxygen concentrator and portable oxygen have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the rental of an oxygen concentrator and 
portable oxygen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64491, 64493, 94495) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would prefer injections instead of 
medication. The Plan denied your request. The Plan says that records show the enrollee does not have neck 
pain that has been evaluated for the suitability of facet injection. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The records show 
that the enrollee does not have documented neck pain that has been evaluated for the suitability of facet 
injection. The enrollee has untreated radiculopathy or neurogenic claudication. In addition, he has failed to 
achieve a minimum of consistent 50% improvement in pain for at least six (6) months after the last radio 
frequency ablation. The notes do not show whether the injections are first or second in a series and whether 
they are diagnostic or therapeutic. The documentation provided also does not show the need for treatment of 
more than one to two levels (unilaterally (one side) or bilaterally (both sides)) in one session. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (64491, 64493, 94495) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood sugar monitoring supplies to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve blood sugar monitoring supplies. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are in-network providers 
available to provide this equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
blood sugar monitoring supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service February 2, 
2022. 
 You asked the Plan to pay for procedure code J2001. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code J2001 is bundled into payment 
for code 64493. 
 
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 J2001 
is a column II code to column I code 64493. 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 procedure code J2001 billed for date of service February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 billed for date of service 
August 31, 2021. 
 
You asked the Plan to pay for procedure codes 87150 and 87641. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 87150 is 
bundled into payment for code 87500 and payment for code 87641 is bundled into payment for code 87150. 
 
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 87150 
is a column II code to column I code 87500, and that code 87641 is a column II code to column I code 87150. 
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 
procedure codes 87150 and 87641 billed for date of service August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression equipment to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression equipment. You say that this is medically necessary 
for your condition. The Plan denied your request. The Plan says there are in-network providers available to 
provide this equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression equipment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82465 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code 82465. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed is 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 CPT code. In this case, we have confirmed that code 82465 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 82465 billed for date of service January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system (A4305) provided August 
16, 2021 to August 22, 2021. 
 
You asked the Plan to pay for the drug delivery system. You say that this device was medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for 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. 
 
We find that CPT code A4305 is not supported in the medical record. Specifically, the service was billed with 
the GY modifier. Items billed with the GY modifier are denied automatically as not medically necessary. Based 
on this information, we decided that Medicare rules for coverage of the drug delivery system have not been 
met. Therefore, we decided that the Plan does not have to pay for a disposable drug delivery system (A4305) 
provided August 16, 2021 to August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5299) provided July 12, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you used a network provider. The Plan denied 
your request. The Plan says this brand of hearing aid is not covered under your benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only you purchase one of the types of hearing aids listed as covered by your plan. 
 
We looked at the file and the Plan's rules. In this case the hearing aids purchased are not covered by your plan. 
The file includes a signed delivery receipts showing that you are responsible for the entire cost of the hearing 
aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5299) provided July 12, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergency ambulance 
transportation (A0428) and ground mileage (A0425) provided on February 20, 2022. 
 
You asked the Plan to waive the copayment for the non-emergency ambulance transportation and ground 
mileage. You say that you should not have to pay for this transport. The Plan denied your request. The Plan 
says the copayment amount you are being charged is correct. 
 
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 $200 
copay per trip, each way for Ambulance services.  
 
 
 You have been asked to pay a $200 copay for the non-emergency ambulance transportation and ground 
mileage. The non-emergency ambulance transportation and ground mileage falls within the Ambulance 
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 the non-emergency 
ambulance transportation (A0428) and ground mileage (A0425) provided on February 20, 2022.