Persius/hicric huggingface dataset:
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 is below their functional baseline and 
has shown they can tolerate intensive therapy. You say the enrollee needs medical monitoring while 
completing therapy in an inpatient setting. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with electronic connection and 
harness, power seat elevation system, and foot plate covers. 
 
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 covered. 
 
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 expandable controller with electronic connection and harness are not medically necessary. Our physician 
reviewer found the enrollee has left hemiplegia but can lift her right arm to near shoulder level. She has 
adequate strength to manage the standard power drive controls; therefore, the requested expandable controller 
with electronic connection and harness are not medically necessary. 
 
The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The requested power seat elevation system and foot plate covers do not serve a purpose that is primarily 
medical in nature. 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 an expandable controller with electronic 
connection and harness, power seat elevation system, and foot plate covers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial mandibular overdenture (D5866) provided on October 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for partial 
mandibular overdenture (D5866) provided on October 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on April 30, 
2022, to May 29, 2022. 
 
You asked the Plan to pay for home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 30, 2022. The NOA has yet to be received. As more than 30 days will 
have passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on 
April 30, 2022, to May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections. 
 
You asked the Plan to pre-approve the epidural steroid injections. The Plan denied your request. The Plan says 
the criteria for coverage has not been met. 
  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 epidural injections. Our reviewer 
says that the request is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support 50% pain relief for 3 months after an epidural steroid injection. 
 
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 epidural injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service 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 your benefit for the requested item or service was exhausted on date of service November 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381). 
 
You asked the Plan to pre-approve D4381. You say that you would like this dental work approved. The Plan 
denied your request. The Plan says D4381 is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
localized delivery of antimicrobial agents (D4381).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the catheter placement provided from 
October 17, 2022, to October 18, 2022. 
 
You asked the Plan to waive the copayment for the catheter placement. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 $325 
copayment for outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the catheter placement. This item/service falls within the 
outpatient surgery 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 catheter 
placement provided from October 17, 2022, to October 18, 2022.
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 enrollee is unable to go home or to a 
skilled nursing facility (SNF) due to their medical complexity. You also say the enrollee is medically stable and 
will benefit to transfer to the LTACH.  You would like reconsideration based on the records submitted. The 
Plan denied your request. The Plan says admission to an LTACH is being denied as not medically necessary. 
 
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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: 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 all physicians involved in the enrollee's 
care concur that LTACH is the appropriate level of care. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
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 appears be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit from July 7, 
2022, to July 12, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as 
an inpatient and should have this copayment waived. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $120 copayment for in-network and out-of-network emergency room visits.  
 
You have been asked to pay a $120 copayment for the emergency room visit. This item/service falls within the 
emergency care 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 emergency room visit 
provided from July 7, 2022, to July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional wound care services. 
 
You asked the Plan to pre-approve additional services. You say that the treatment is needed to heal the wound. 
The Plan denied your request. The Plan says the maximum number of applications has been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that skin substitute wound care is only covered under 
certain medical indications.  

We looked at the file and Medicare rules. The original request was for 12 applications. The Plan has agreed to 
pre-approve 10 applications. Medicare rules does not allow treatments to exceed 10 applications. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional wound care 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 it is medically necessary. 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 complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for seizures and hyponatremia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure improves the quality of 
life. The Plan denied your request. The Plan says the service is contraindicated for the enrollee's condition. 
 
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 is being treated for intervertebral disc degeneration of the lumbar region and 
vertebrogenic low back pain. Overall, documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at 
L5-S1, in this case, is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intraosseous ablation of the basivertebral nerve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that procedure code 76140 is coded 
appropriately. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glassia 1 GM/50 ML Vial. 
 
You asked the Plan to pre-approve Glassia 1 GM/50 ML Vial. The Plan denied your request. The Plan says 
Glassia 1 GM/50 ML Vial is not being used for a medically accepted reason. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Glassia 1 GM/50 ML Vial.   
Benefits for Glassia 1 GM/50 ML Vial may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for July 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99306 is not supported by the medical records. 
 
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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that procedure code 99306 is not supported by the medical records. Our reviewer found the enrollee was hospitalized for weakness, 
anemia, and sepsis due to hardware infection from the knee. She was treated with antibiotics and iron. She was 
transferred to a skilled nursing facility and on July 6, 2022 her brief history was redescribed. The physical 
examination was limited and focused. She had knee pain that was managed with medication and was otherwise 
stable. There is insufficient evidence of medical decision making of high complexity and there is no 
comprehensive history for the date of service at issue to support the billing of code 99306. 
 
We looked at this coder'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 pay for procedure code 99306 billed for July 6, 2022.