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 patient can tolerate three hours of therapy daily 
and has a good prognosis to benefit from intensive therapy to be able to return to the community. You say that 
the patient requires therapy services and 24-hour nursing. The Plan denied your request. The Plan says the 
enrollee does not meet functional or medical necessity 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 that there is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Although the enrollee continues to have a need for skilled therapy, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility. The 
enrollee can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you will not be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain your functional status. You can receive further services at a lower 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: 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 enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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 pay for outpatient clinic services provided to the enrollee on 
September 30, 2021. 
 
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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that the denied codes are not supported in the medical record. Specifically, if multiple medical visits 
are reported with the same revenue center, condition code G0 must be reported. This was not done on this 
claim. 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 outpatient clinic services provided to the 
enrollee on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing 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 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 infectious agent testing provided on August 17, 2021, 
billed with codes 87500, 87481, 87491, 87491, 87591, 87640, 87653, 87651, 87661, 87150, 87641, and 13 
units of 87798. You asked the Plan to pay for the lab testing as billed. You say that this is correctly billed for the testing 
provided. The Plan denied your request. The Plan says this is not correctly billed as all codes are inclusive to 
the paid code 87801. 
 
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 the billed codes are Column 2 in relation 87801. Modifier -XU was 
reported which is defined as "unusual non-overlapping service, the use of a service that is distinct because it 
does not overlap usual components of the main service." This is not supported by the records. The testing of 
each individual organism would be included in the main code. There is no evidence that these were for 
different samples or that the sample was tested multiple times. The use of the modifier to bypass these edits is 
not supported. Therefore, we decided that the Plan does not have to pay for the infectious agent testing 
provided on August 17, 2021, billed with codes 87500, 87481, 87491, 87491, 87591, 87640, 87653, 87651, 
87661, 87150, 87641, and 13 units of 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cane or walker holder for a power wheelchair 
(K0108). 
 
You asked the Plan to pre-approve the cane or walker holder. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says this feature is not considered primarily medical in nature and is 
non-covered. 
 
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 cane or walker holder for a power wheelchair (K0108).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the 
hospital the member had stabilized medically. The member did not require any skilled nursing or rehab services 
on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
self-care tasks. The member did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF 
level of care at the time of discharge from the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular interim partial denture (D5821). 
 
You asked the Plan to pre-approve the mandibular interim partial denture. You say that you cannot afford to get 
this denture. The Plan denied your request. The Plan says this service is not covered under your benefit 
package. 
 
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 a 
mandibular interim partial denture (D5821).
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 IRF care is needed because you are fresh out of 
surgery. The Plan denied your request. The Plan says IRF care is not medically necessary and you can be 
managed at a lower 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 
care needs can be met at a lower 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extractions to be performed in the outpatient 
hospital setting. 
 
You asked the Plan to pre-approve the dental extractions to be performed in the outpatient hospital setting. You 
say that you would like your hospital care covered. The Plan denied your request. The Plan says the dental 
extractions are not covered under your medical benefit for your condition. The Plan states that dental 
extractions may be covered in some instances under your dental benefit for non-medical services up to your 
maximum coverage limit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. The dental extractions being requested are not related to reconstruction of the jaw 
following accidental injury or to prepare for radiation treatment of neoplastic diseases involving the jaw.  
Thus, the dental extractions to be performed in the outpatient hospital setting are not covered under your 
medical benefit. Therefore, we decided that the Plan does not have to pre-approve the dental extractions to be 
performed in the outpatient hospital setting.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services provided on November 9, 
2021, billed with code 99100. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your 
request. The Plan says the main anesthesia code was paid, but payment for 99100 is bundled with this payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99100 has a status indicator of "B" on the Medicare Physician Fee Schedule. This means that payment for 
this service is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not 
have to pay for the special anesthesia services provided on November 9, 2021, billed with code 99100.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional routine transportation. You say that you need additional trips. The 
Plan denied your request. The Plan says your benefit covers up to 10 routine transportation trips per plan year. 
Additional trips are not a covered 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 10 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional level of bilateral transforaminal epidural 
injections. 
 
You asked the Plan to pre-approve an additional level of bilateral transforaminal epidural injections. You say 
that this is medically necessary. The Plan denied your request. The Plan says the maximum number of injection 
services have been reached. 
 
The Plan follows Medicare rules. Medicare rules say that transforaminal epidural steroid injections are limited 
to 2 levels unilaterally or one level bilaterally 
 
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 an additional level of bilateral 
transforaminal epidural injections. Our reviewer says that the requested services are not medically reasonable 
and necessary. Our physician reviewer found that this 64-year-old gentleman has radicular low back pain.  The 
request is for 2 levels bilaterally of transforaminal epidural steroid injections.  LCD limits the utilization to 2 
levels unilaterally or one level bilaterally. The request for a second level bilaterally 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 an additional level of bilateral transforaminal epidural injections have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an additional level of bilateral 
transforaminal epidural injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite dental filling (D2392) provided on 
September 21, 2021. 
 
You asked the Plan to pay for resin-based composite. You say that the service at issue was the replacement of a 
temporary filling with the permanent. The Plan denied your request. The Plan says rules for payment for dental 
services have not been met. 
 
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 Plan covers resin-based 
composite once in 12 months for the same tooth and surface.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of resin-based composite have not been met. Specifically, the Plan has documented that you had 
already received the service coded D2392 in the 12 months prior to the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for a resin-based composite dental filling (D2392) provided on 
September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740), core buildup, including any pins when required (D2950), and endodontic therapy, molar tooth 
(excluding final restoration) (D3330) provided December 3, 2021. 
 
You asked the Plan to provide additional payment for the crown, core buildup and root canal. You say that you 
had not been to a dentist in 3 years, and you do not understand how your $1,000 benefit can be exhausted. The 
Plan denied your request. The Plan says your annual dental allowance has been exhausted, and no further 
payment is due. 
 
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 Plan covers the crown, 
core buildup and root canal up to the Plans annual dental maximum.  
We looked at the file and Medicare rules. The Plan provide documentation showing that your full $1,000 
annual dental maximum has been applied to services provided on December 3, 2021. Therefore, we decided 
that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740), core 
buildup, including any pins when required (D2950), and endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the re-cement or re-
bond of crown (D2920) provided on December 13, 2021. 
 
You asked the Plan to pay for dental codes D0140 and D2920. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0140 and 
D2920 are not covered under the Plan's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D0140 and D2920 are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the re-cement or re-bond of crown (D2920) provided on December 13, 2021.