Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine-transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that the requested additional trips are a necessity 
for your care. The Plan denied your request. The Plan says you have exhausted the annual transportation 
benefit. 
 
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. The Plan covers a maximum of 50 one-way, non-emergency trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine-transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve permanent percutaneous epidural implantation of the 
neurostimulator electrode array (63650) and implantable neurostimulator electrode, each (L8680). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator. You say that despite 
multimodal and interdisciplinary interventions, including conservative and surgical measures, the enrollee 
continues to have chronic lumbar radicular pain. The Plan denied your request. The Plan says the request is not 
medically necessary because there is not enough documentation that the enrollee is not a surgical candidate. 
 
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 percutaneous implantation of 
neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the lumbar x-ray of May 21, 2021 notes the presence 
of posterior spinal stimulator lead. Only one SCS trial per lifetime is allowed.  The enrollee has a lead in place. 
Therefore, the request is deemed not medically reasonable or 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 percutaneous implantation of neurostimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve permanent percutaneous epidural implantation of the 
neurostimulator electrode array (63650) and implantable neurostimulator electrode, each (L8680).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request was denied due to a lack of medical necessity. 
 
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. Our reviewer found that the original case file contained no records. A request for 
records resulted in the provision of records for the wrong patient. As such, the health plan has failed to 
substantiate their denial. There are no records to support the health plan's denial. Therefore, we decided that the 
Plan has to pre-approve home health services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4649 billed for date of service September 24, 2021, to 
November 26, 2021. 
 
You asked the Plan to pay for code A4649. The Plan denied your request. The Plan says code A4649 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that code A4649 has a status indicator of P on the Physician Fee Schedule. This means that code A4649 is bundled/excluded and is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of code A4649 have not been met. Therefore, we decided that the Plan does not have to pay 
for code A4649 billed for date of service September 24, 2021, to November 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the head or brain CT scan (CPT code 71045) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says payment for code 70450 is bundled into payment for code 32555. 
 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 70450 
is a column II code to column I code 32555. 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 the head or brain CT scan (CPT code 71045) provided on 
December 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says this request is not 
reasonable and necessary because no skilled nursing needs are identified. 
 
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. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you along with other attending 
physicians have determined that the enrollee cannot be adequately cared for in the current condition at a lower 
level of care You say that level of care has failed twice and the enrollee is ready for transfer to LTAC. The Plan 
denied your request. The Plan says admission to LTACH was denied as not meeting criteria, is not medically 
necessary, and continued acute hospital stay was offered until the enrollee could discharge to a lower level of 
care. 
 
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 was admitted to the acute care hospital with ankle abscess status 
post hardware removal requiring wound debridement, wound vacuum-assisted closure, and intravenous 
antibiotics. The course was complicated by anemia, cirrhosis, portal hypertension, hypokalemia, and QT 
prolongation and was treated with paracentesis. Recent notes describe the enrollee with clinical improvement 
and stable vitals but requiring additional wound care and antibiotic treatment. The enrollee is receiving 
appropriate care at the present setting. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient care and do 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 you require services that you are not 
currently receiving but that would be available at the LTACH facility. Our reviewer found that the elements of 
the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the analysis of 11 endogenous analytes coded 0117U 
provided on January 5, 2022.  
You asked the Plan to pay for the analysis of 11 endogenous analytes. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that there is no evidence to support the referring provider/ordering provider is or was 
treating the enrollee. This means that there is no documentation to support that the analysis of 11 endogenous 
analytes testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the analysis 
of 11 endogenous analytes coded 0117U provided on January 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for swing bed care provided from September 16, 2021, to 
September 20, 2021. 
 
You asked the Plan to pay for swing bed care. The Plan denied your request. The Plan says a corrected claim is 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of swing bed care provided from September 16, 2021, to September 20, 2021 have been met. A corrected claim is required. Therefore, we 
decided that the Plan does not have to pay for swing bed care provided from September 16, 2021, to 
September 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 25, 2021, to November 23, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation does not contain required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted did not include a valid physician's order for the skilled care, physical therapy, and 
occupational therapy services billed. The submitted physical order is dated November 26, 2021 but has a signature date of November 8, 2021. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from October 25, 2021, to November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long term 
acute care hospital admission. The Plan denied your request. The Plan says we reviewed the clinical 
information provided. Based on information provided, medical necessity is not 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 the enrollee was admitted to the acute care hospital with a urinary tract infection, 
sepsis, complicated by indwelling foley catheter, hypotension, rectal bleeding, coughing during speech therapy, 
and ogilvie syndrome. The enrollee was treated with antibiotics, fluids, vasopressors, colonoscopy, rectal tube, 
heparin drip, and nothing by mouth. The enrollee is receiving appropriate care at the present setting. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 needs IRF admission to be able to 
function at home. The Plan denied your request. The Plan says the enrollee does not meet criteria. The Plan 
will continue to follow the enrollee and will be considered for skilled nursing facility services as appropriate. 
 
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 to an acute hospital on August 28, 2022 with diarrhea and 
dehydration.  The enrollee was found to have sepsis, an acute kidney injury and a large right ureteral stone with obstruction 
calculus and underwent emergent cystoscopy. The enrollee was treated and stabilized and is left with severe 
debility. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on March 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the testing was billed 
incorrectly.  
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root  
(D7140 x 8) provided on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that your dental benefit was exhausted on date of service April 6, 2022. Specifically, the Plan contract 
says that enrollees have a maximum dental benefit coverage of $1,000 per calendar year. You previously 
received dental services on April 6, 2022. These services were paid for by the Plan on April 22, 2022 in the 
amount of $1,000; therefore the dental benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the extractions, of an erupted tooth or exposed root (D7140 x 8) provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic surgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you were given a referral to the doctor. The 
Plan denied your request. The Plan says there are in-network providers that can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that it is difficult for the enrollee to use 
lancets and test strips. The Plan denied your request. The Plan says the enrollee takes insulin on a fixed dose. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.