Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you require an extended acute 
hospitalization before being ready for a lower level of care. The Plan denied your request. The Plan says it is 
not safe for you to leave the hospital at this time because your neurologic status is poor. You are receiving the 
care you need in the hospital where you are now and there is no need to transfer to the LTACH at this time. 
 
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 you were admitted with diabetic ketoacidosis after a fall.  The record indicates that 
you continue to be critically ill with metabolic encephalopathy and require ongoing acute care services.    You 
continue to receive acute care services, and these have not been denied.  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.  
 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit (99285) provided on March 17, 
2021. 
 
You asked the Plan to pay for the emergency room service. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency room visit (99285) provided on March 17, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the needed care is being received in the hospital where the enrollee is now. 
 
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 with shortness of breath due to pleural effusion. The record 
indicates that the enrollee has had a complicated hospital course and remains critically ill, requiring acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service December 
11, 2021. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 procedure code 71045 billed for date of service December 11, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is asymptomatic, and the requested test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
 
  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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee had a recent CT scan of the chest that showed ground glass pulmonary opacities. The enrollee is 
currently asymptomatic with a normal lung examination. The provided records do not indicate the medical 
necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of 
the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest for the enrollee.
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 you are attempting to prevent another 
readmission and the enrollee cannot be optimally restored at any other level of care. You say that an LTACH is 
the most appropriate level of care due to the complexity of the care. The Plan denied your request. The Plan 
says the member is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The record 
indicates that the enrollee is improving but still requires acute care services. The records do not indicate that the 
enrollee requires services that she is not currently receiving but would be available at the LTACH facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft procedure. 
 
You asked the Plan to pre-approve VIA Disc allograft. You say that VIA Disc procedure is appropriate 
indicated for the enrollee based on the enrollee's clinical condition. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because studies have not proven that this is helpful 
for treatment of 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 VIA Disc allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve VIA Disc allograft procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the viscosupplementation injection services. 
 
You asked the Plan to pre-approve the viscosupplementation injection services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy to be approved, 
conservative therapy must have been failed. 
 
We looked at the file and Medicare rules. In this case, there is no documentation of conservative therapy. 
dBased on this information, we decided that Medicare rules for coverage of the viscosupplementation injection 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
viscosupplementation injection services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
14, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service December 14, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 20, 
2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service October 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous electrical nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conventional 
treatment options. The Plan denied your request. The Plan says the stimulator is not being requested as a trial 
for a permanent device. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulators are only covered 
under certain medical indications.  
 
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 has chronic low back pain. He has tried Physical Therapy. The request is for 
bilateral insertion of percutaneous nerve stimulators. Current peer review literature does not support the 
requested treatment for low back pain. The request 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 a percutaneous electrical nerve stimulator.
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 you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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 at your current functional level you are not appropriate for acute rehabilitation.  You do not need intensive therapies consisting of at least 3 hours of therapy per day for at least 5 days per 
week with a multidisciplinary approach to daily therapy. IRF admission is not appropriate based on medical 
instability and your lack of rehabilitation nursing needs. 
 
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 transurethral waterjet ablation of the prostate. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says the enrollee's prostate volume is greater than the parameters. 
 
The Plan must follow Medicare rules. Medicare rules say waterjet ablation of the prostate is only covered under 
certain medical indications.  
 
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 has urinary retention. Treatment with tamsulosin and oxybutynin has not been 
effective. CT indicates a large bladder diverticulum and thickened bladder wall. Elevated PSA was evaluated 
with ultrasound guided biopsy revealing a 218.03 cc prostate with Gleason's grade 3+3 adenocarcinoma 
involving the right base. The criteria have not been met as the enrollees prostate size is outside of the 
parameters require for coverage.  
 
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 a transurethral waterjet ablation of the prostate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full urinary tract infection panel (87481, 87491, 87500, 
87529, 87556, 87591, 87641, 87661, 87798). 
 
You asked the Plan to pay for the laboratory services. You say that the ordering physician sent the specimens to 
your laboratory. Based on the enrollee's specific clinical situation, the enrollee's physician ordered the 
performed tests. The testing exceeds the enrollee's medical needs. The Plan denied your request.  The Plan says there is lack of support for the clinical utility of large multiplex PCR urinary tract infection panel 
tests. There is lack of data to suggest these panels alter medical decision making. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for full urinary tract infection panel (87481, 87491, 87500, 87529, 87556, 87591, 87641, 87661, 87798).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on October 28, 2021. 
 
You asked the Plan to pay for the dental service. You say that you would like this service to be covered. The 
Plan denied your request. The Plan says bone replacement graft for ridge preservation is not a covered service. 
 
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 bone replacement graft for ridge 
preservation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the bone replacement graft for ridge preservation (D7953) provided on October 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperbaric oxygen (HBO) therapy (99183) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the HBO therapy. You say that the services should be covered. The Plan denied 
your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that continued treatment with HBO therapy is not covered 
if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  
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 HBO therapy. Our reviewer says that the 
hyperbaric oxygen therapy is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the criteria for coverage were met. The reviewer also found that the 
hyperbaric oxygen therapy is not medically necessary or reasonable. 
 
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 HBO therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for the hyperbaric oxygen (HBO) therapy (99183) provided on September 10, 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 you feel as though you could use intensive 
rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF service is 
correct. 
 
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 are not shown to require - or to be able to tolerate - 15 hours per week of 
rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care 
such as 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
18, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service December 18, 
2021.