Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of home health services for skilled nurse 
visits. 
 
You asked the Plan to pre-approve continuation of home health services for skilled nurse visits. You say that 
the member is not able to control urinating and soiling and the member has dementia and is bedridden. You say 
that the doctors recommended this due to the member's physical care and safety as the member is not able to do anything for herself at this point. The Plan denied your request. The Plan says continuation of home health 
services for skilled nurse visits is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continuation of home health services 
for skilled nurse visits. Our reviewer says that continuation of home health services for skilled nurse visits is 
not medically necessary. Our physician reviewer found that based on the medical records provided there is no 
documentation that further skilled nursing services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollees condition and/or prevent deterioration. The most recent nursing records available in this 
case are from June 2, 2022, which show at that time the sacral wound was reported to be stage 1 and was free 
of odor or drainage with a pink wound bed. At that time the treatment was to clean the wound with normal 
saline or a wound cleanser, pat dry and apply a Mepilex dressing every three days. Calmoseptine cream was 
recommended as needed to prevent further skin breakdown. The provided records do not document any acute 
or unstable medical conditions or changes in medication or treatment, which would necessitate any further 
skilled nursing visits beyond what have already been approved. No medical notes from the enrollees treating 
physician are provided documenting an order or need for additional skilled nursing services. The records do not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound 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 continuation of home health services for skilled nurse visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continuation of home health services for 
skilled nurse visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant of a Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion interspinous spacer device. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 Superion interspinous spacer 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Superion spacer device is experimental. More research 
is needed before coverage can be approved. 
 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 Superion interspinous spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the implant of a Superion interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the anti-reflective coating (V2750). We decided that the Plan does not 
have to pay for the polycarbonate lens (V2782).  
 You asked the Plan to pay for the anti-reflective coating (V2750) and polycarbonate lens (V2782) provided on 
March 15, 2022. You say that these services were medically necessary to achieve maximum vision, and new 
lenses were prescribed. The Plan says that the documentation received does not document the medical 
necessity of anti-reflective coating. The Plan also says the polycarbonate lens is not covered. 
 
We decided that the Plan has to pay for the anti-reflective coating (V2750).  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the anti-reflective coating (V2750) by a contract provider. The file does not show that 
the Plan provided notice that the anti-reflective coating (V2750) would not be covered. Under Medicare rules, 
this means the anti-reflective coating (V2750) is considered approved by the Plan. Therefore, we decided that 
the Plan has to pay for the anti-reflective coating (V2750).  
 
We also decided that the Plan does not have to pay for the polycarbonate lens (V2782). 
 
The Plan follows Medicare rules. Medicare rules say that the use of high index glass or plastic (V2782, V2783) 
for indications such as light weight or thinness will be denied as a non-covered deluxe feature. Therefore, we 
decided that the Plan does not have to pay for the polycarbonate lens (V2782). 
 
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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical conditions appear stable on outpatient medications with no issues that appear to require a physicians evaluation three or more times per week. You 
do require physical therapy and occupational therapy services, but the medical records provided do not clarify 
why you require an intensive inpatient rehabilitation therapy program. Provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as 
in a skilled nursing facility is not appropriate for you. There is concern that you will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to your reported level of decreased endurance. Our physician reviewer found that 
your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the enrollee is a good candidate for 
the requested procedure, and he can gain much by having this device. You say that the records provided 
support the need for a CardioMEMS system. The Plan denied your request. The Plan says the CardioMEMS 
system is not going to be used for the enrollee's care in a Medicare-approved medical research study. 
 
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 a CardioMEMS system. Our reviewer 
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 7, 2022, 
to February 5, 2022. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 7, 2022, to February 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220 X 2), 
extraction, erupted tooth, or exposed root (D7140), and extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided from February 22, 2022, to March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is in-network. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for intraoral - periapical first radiographic image (D0220 X 2), extraction, erupted tooth, or exposed root 
(D7140), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided 
from February 22, 2022, to March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (procedure code 98941) provided to the 
enrollee on March 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service was billed incorrectly. 
 
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 98941 is "Chiropractic manipulative treatment." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there are no medical records that 
show that there were services provided to the patient. 
 
We looked at this coder's review, the file, and Medicare rules. 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 chiropractic services (procedure code 98941) provided to the enrollee on March 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney ultrasound at a tertiary level of care. 
 
You asked the Plan to pre-approve a kidney ultrasound at a tertiary level of care. You say that the need for a 
tertiary level of care is supported by the records provided. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for tertiary care. 
 
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 a kidney ultrasound at a tertiary level of 
care. Our reviewer says that a tertiary level of care is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the test ordered does not require any expertise that would not be available 
at a typical imaging center. This is a routine study that does not require a special level of expertise to warrant 
going to a center of higher level of care. There is nothing documented to support the need for a higher level of 
care. The study can be provided at the center the Plan has made available with no compromise in care to 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 a kidney ultrasound at a tertiary level of care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a kidney ultrasound at a tertiary level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a lumbar interspinous process 
stabilization device without decompression or fusion (22870) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this will improve the enrollee's quality of life. 
The Plan denied your request. The Plan says that this has not been shown to be safe and effective in long term 
studies. 
 
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. Lumbar interspinous 
devices are experimental. More research is needed. 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 the insertion of a lumbar interspinous process stabilization device without decompression 
or fusion (22870) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6535 for 
the enrollee. 
 
You asked the Plan to pre-approve the compression stockings. You say that these are being requested for leg 
pain due to varicose veins. The Plan denied your request. The Plan says that this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6535 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6535 for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided January 
11, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that you are requesting review of the attached 
emergency department record, reprocess and approve the claim at the appropriate reimbursement rate for the 
evaluation and management code billed. The Plan denied your request. The Plan says the plan downgraded and 
paid for 99284 Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 pay for the emergency visit Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer 
found the enrollee, with a history of atrial fibrillation and a former smoker, presented to the emergency 
department with 3-4 days of abdominal pain. The enrollee was evaluated with a physical exam, laboratory 
studies, EKG and CT abdomen and pelvis. The enrollee was diagnosed with atrial flutter and a UTI. The 
enrollee was treated with oral antibiotics and discharged home on 01/12/2022 with outpatient Gastroenterology 
follow-up. The review indicates that there was no documentation of medical decision making of high 
complexity. The review has determined that the use of 99285 was not supported by the medical records. 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided January 11, 2022.
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 medical records provided support the medical 
necessity of IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary. The 
Plan says that the enrollee's current 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 the complexity of the enrollee's 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 cardiac arrest and coronary artery bypass grafting. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a different 
level of care. 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.