Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the orthopedic office visit. You say that the in-network provider is not board 
certified and will not have the proper equipment to treat the enrollee. The enrollee knows there are no in-
network providers that can support a metal artifact reduction sequence magnetic resonance imaging (MARS 
MRI). The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 orthopedic office visit. We found no exception that would require the Plan to 
pre-approve the orthopedic office visit. Therefore, we decided that the Plan does not have to pre-approve the 
orthopedic office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that it is safe for the enrollee to leave the 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that it is not safe for the enrollee to leave the 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. The enrollee 
is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that it is not safe for the enrollee to leave the 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. The enrollee 
is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the 
LTACH that are not available at the acute care hospital where he/she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nineteen (19) additional miles for routine transportation. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that the requested 
service is covered under you Plan. The Plan denied your request. The Plan says the requested amount exceeds 
the limit listed by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Review of the file shows that you 
are requesting 19 additional miles for routine transportation. Your 2022 EOC states each one-way trip must not 
exceed 50 miles of driving distance. Therefore, this request exceeds your benefit because the 51st mile and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve nineteen (19) 
additional miles for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a step stool. 
 
You asked the Plan to pre-approve a step stool. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered by Medicare. 
 
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 pre-approve a step stool.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29828 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 29828. You say that the medical records support the billing of 
this code. The Plan denied your request. The Plan says procedure code 29828 is not supported in the medical 
records. All other codes billed were approved. For code 29828, the operative report did not include 
documentation of a surgical should arthroscopic biceps tenodesis, so this code cannot be verified. 
 
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, the CPT Code Manual definition of code 29828 is Arthroscopy, shoulder, surgical; biceps 
tenodesis. 
 
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 code 29828. Our reviewer says that code 29828 is 
not supported in the medical record. Our reviewer found in order to code the procedure the documentation will 
have to read "She inserts additional instruments to repair an unstable biceps tendon, the fibrous band that connects the biceps muscle in the forearm to its bony attachment at the shoulder join. Biceps tenodesis corrects 
instability of the biceps tendon due to biceps tendonitis, inflammation of the tendon" which was not apparent or 
described in the procedure report. Therefore this code could not be verified. 
 
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 code 29828 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 29828 billed for date of service March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer (22869). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee has failed conservative 
approaches including physical therapy, medications, injections and various non-sustainable treatments. The 
Plan denied your request. The Plan says the requested service 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 surgical service. Our reviewer says 
that the requested interspinous spacer is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the interspinous spacer device is considered experimental and therefore 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an interspinous spacer (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a behavioral health/substance abuse 
facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says treatment needs can be met in a less restrictive setting. 
 
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 admission. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on a review of the records provided, it was not expected that you would improve in a 
reasonable period of time as you did not have dangerousness to self or others, auditory or visual hallucinations, 
delusions. You were not showing any behavioral issues. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health 
plans denial of inpatient psychiatric services appears 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a behavioral health/substance abuse facility.
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 services requested are medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate inpatient acute 
care and does not require transfer to 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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97026, 97810, 97811) provided 
December 13, 2021 to December 20, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this type of provider is not eligible for enrollment in Medicare and is 
not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Licensed Acupuncturists are not eligible for 
enrollment in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not eligible to be enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for acupuncture services (97026, 
97810, 97811) provided December 13, 2021 to December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 18, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from February 8, 2021, to February 28, 
2021. 
 
You asked the Plan to pay for home health services. You say that you have tried to get the provider to bill a 
corrected claim. The Plan denied your request. The Plan says that this was billed with a missing CPT code, and 
the Plan is not responsible for balance billing. 
 
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. Although the Plan states that these services were not billed correctly, the 
submitted documentation did not include a claim showing how these services were billed. Without this 
information, the Plans denial cannot be verified. Therefore, we decided that the Plan has to pay for home 
health services provided from February 8, 2021, to February 28, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arterial x-rays to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you would like to remain with this physician. 
The Plan denied your request. The Plan says the medical car you require can be provided by a network 
provider. 
 
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 
arterial x-rays to be provided by an out-of-network (OON) provider.
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 the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
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 that the enrollee is improving but still requires acute-care services. The enrollee 
continues to receive acute-care services and these have not been denied. The medical record does not indicate 
that the enrollee requires services that the enrollee is not currently receiving but that would be available at the 
LTACH facility. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can receive the physical therapy that is recommended in 
another setting. 
 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. There 
are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutritional therapy (MNT) (97802) provided on 
September 29, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that this procedure code has been 
used on previous Medicare claims and paid. You also say that the enrollee was referred to a registered dietician 
by their physician for MNT for type 2 diabetes. The Plan denied your request. The Plan says MNT is covered 
by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutritional therapy (MNT) (97802) provided on September 29, 2021.