Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for admission to SNF have not 
been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between the power tilt seating 
feature and the main drive control (E2310) and calf support pads (K0108) for use with an approved power 
wheelchair. 
 
You asked the Plan to pre-approve the electronic connection and calf support pads. You say that it is felt that 
all requested items should be approved. The Plan denied your request. The Plan says the two denied items are 
not medically necessary. 
 
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 electronic connection and calf support pads. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the documentation does not reveal that the enrollee is unable to use 
the approved power tilt option through its own switch that is included in the approved wheelchair with her 
unaffected upper extremity. The E2310 exceeds the enrollee's medical needs. The K0108 Calf Support exceeds 
the enrollee's medical needs as the approved wheelchair already has calf rest/pad included in the wheelchair.  
 
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 electronic connection and calf support pads have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an electronic connection between the power tilt seating 
feature and the main drive control (E2310) and calf support pads (K0108) for use with an approved power 
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from May 13, 2022, to May 
15, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the inpatient stay was medically necessary at 
the acute level of care. The Plan denied your request. The Plan says the services provided were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient services. Our reviewer says that 
the documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department from the dialysis center with weakness on 
their left side, tingling, and pain with left facial droop. The enrollee arrived alert and oriented with Glasgow 
Coma Scale (GCS) 15, National Institutes of Health (NIH) stroke score of 0, without slurred speech, no 
changes with vision. Our reviewer found that the symptoms had resolved, and physical examination revealed 
no focal deficits. Labs, electrocardiogram, imaging, vitals were all stable or unremarkable. Our physician 
reviewer also found that the initial presentation and workup suggested very low likelihood of stroke or any 
other acute process requiring inpatient care that would have lasted 2 midnights. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient services provided from May 13, 2022, to May 15, 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 you do not have enough money to stay at the current 
skilled nursing facility. You also say that you need more rehabilitation before going home. The Plan denied 
your request. The Plan says this request is not medically necessary. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. Our reviewer found that medically 
necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you 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: 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 had a stroke, they were able to care and 
do things for themself. You also say that you would like this service to be approved for coverage. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
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 he 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. Our reviewer 
found that 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. Our physician reviewer also found that 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy (PT) visits to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 7 additional PT visits. The Plan denied your request. The Plan says the 
information received does not meet criteria for approval for PT visits to be rendered by an OON provider 
because you have in-network physical therapists available in your area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
7 additional physical therapy (PT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on November 30, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the provided records show full medical necessity, and you would like this claim to be reprocessed. The Plan 
denied your request. The Plan says non-emergency ambulance transportation is covered when it is the only way 
to safely and adequately transport an enrollee, or if other means of transporting an enrollee are unsafe due to a 
medical condition. The Plan also says that this claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our physician reviewer found the record indicates that the enrollee required 
an inter-facility transportation for long term dementia care. The record does not indicate that the enrollee's 
clinical condition is such that other methods of transport, such as stretcher van, were contraindicated or that the 
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could 
provide was required. Our reviewer found that the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84479 and 84436 billed for date of service 
April 29, 2022. 
 
You asked the Plan to pay for procedure codes 84479 and 84436. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says payment for codes 84479 and 84436 is 
bundled into payment for code 84439. 
 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 codes 
84479 and 84436 are both column II codes to column I code 84439 with a modifier indicator of 0. The column 
II codes are therefore not payable. 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 codes 84479 and 84436 billed for date 
of service April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64612 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 64612. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says you did not bill with the required anatomic modifier for 
this code. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for code 64612, providers should be 
the appropriate anatomic modifier.  This could be 50 (to indicate a bilateral service), LT (to indicate the service 
was performed on the left), or RT (to indicate the service was performed on the right).  You did not bill any 
anatomic modifier with code 64612 as is required. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64612 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 64612 billed for date of service August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care associated with an elective right total 
shoulder arthroplasty and a should brace. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care is medically necessary. 
The Plan denied your request. The Plan says that there is no documentation provided to support the expectation 
the enrollee will require a greater than 2 midnight stay.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee has a medical history which includes anemia, thyroid disease, neuropathy, high 
blood pressure, heart disease, kidney disease; anticoagulant use; and pacemaker. This past history could place 
this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. Therefore, the record 
does show that at the time of inpatient admission, the admitting physician reasonable expected that the patients 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care associated with an elective right total shoulder arthroplasty and a 
should brace.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82785-59 billed for date of service February 
9, 2022. 
 
You asked the Plan to pay for procedure code 82785-59. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 82785 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 82785 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 82785-59 billed for date of service February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 29, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that these services are supported as billed. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a bridge (false tooth for bridge Tooth 10 (D6240) and white glass 
with high gold content cap for bridge teeth 9 and 11 (D6750)). 
 
You asked the Plan to pre-approve a bridge. You say that this is the best option for the enrollee. The Plan 
denied your request. The Plan says that the provided information does not tell us why a denture cannot be used 
to replace the missing teeth. 
 
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. The Plan covers a bridge when 
the services are medically necessary and reasonable. 

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 bridge. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that a review of the 
documentation indicates that tooth10 is the only missing tooth and the abutment teeth (9 and 11) have good 
bone support. Replacing missing tooth 10 with a fixed bridge is the better option compared to a removable 
appliance to remove a single maxillary anterior tooth. The documentation provided meets the criteria for 
coverage for a fixed bridge replacing tooth 10 with a pontic (D6240) using teeth numbers 9 and 11 as abutment 
retainers (D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a bridge have been met. Therefore, we decided that the Plan has to pre-approve 
a bridge (false tooth for bridge Tooth 10 (D6240) and white glass with high gold content cap for bridge teeth 9 
and 11 (D6750)).  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for medications provided on September 12, 2022. 
 
You asked the Plan to waive the cost sharing for medications. You say that you met your maximum Out-Of-
Pocket in April 2022. The Plan denied your request. The Plan says that the cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not provide documentation proving that you did not meet your 
maximum Out-Of-Pocket prior to this claim. Therefore, we decided that the Plan has to waive the cost sharing 
for medications provided on September 12, 2022.  
 
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.