Persius/hicric huggingface dataset:
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can safely be met in the current hospital setting.
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 patient was admitted for encephalitis, transaminitis, sacral fractures, and T7 compression fracture. 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 pre-approve radiofrequency ablations (RFAs).
You asked the Plan to pre-approve RFAs. You say that you have already had nerve blocks in the past and you
are in pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because the record does not show that you have had pain and impairment of function for more than 3 months.
The Plan follows Medicare rules. Medicare rules state that facet joint interventions such as radiofrequency
ablations may be covered under certain circumstances.
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 RFAs. Our reviewer says that you do
not meet the Medicare criteria for the requested radiofrequency ablations. Our physician reviewer found it has
been more than 2 years since your last radiofrequency ablation procedure, therefore Medicare requires repeat
diagnostic medial branch blocks. There is also a frequency limit of 2 levels of radiofrequency ablations, but this
request is for 4 levels.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of RFAs have not been met. Therefore, we decided that the Plan does not have to
pre-approve radiofrequency ablations (RFAs).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found you have a diagnosis of osteoporosis. The documentation does not support that you have tried and failed
zoledronic acid (generic Reclast). Based on the medical records provided there is no sound clinical information
to show that zoledronic acid (generic Reclast) would likely be less effective and/or likely have adverse effects
for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Grafix Prime skin substitute applications for the
enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the notes do not show that your wound has evidence of adequate
circulation or oxygen.
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. The enrollee
underwent arterial intervention on December 1, 2021. She has not had documented failure to heal the left leg
wound with standard wound treatments. She had a normal Venous Duplex on November 11, 2021. The leg
wound is not venous and a wound biopsy may be indicated. Our physician reviewer found that the enrollee's
condition does not meet criteria 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Grafix Prime skin substitute applications for the enrollee.
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 need inpatient rehabilitation services. The Plan
denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the
services you need in an alternate setting.
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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy services. You say that you are not able to drive.
You say that the requested OON provider is located in the same neighborhood as you. The Plan denied your
request. The Plan says medically necessary care is available in-network.
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
physical therapy services to be provided by an out-of-network (OON) provider.
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 the enrollee is ready for discharge from the current hospital and requires extended acute care at an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous vertebral augmentation (PVA).
You asked the Plan to pre-approve percutaneous vertebral augmentation (PVA). You say that this procedure would benefit the enrollee. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the record does not show that the enrollee's fracture was recent.
The Plan follows Medicare rules. Medicare rules state that percutaneous vertebral augmentation (PVA) may be covered under certain conditions. 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 percutaneous vertebral augmentation (PVA). Our reviewer says that the enrollee meets the Medicare criteria for percutaneous vertebral augmentation (PVA). Our physician reviewer found the enrollee has chronic low back pain. She has multiple vertebral body fractures, but one at L2 was noted to be acute. The fracture has occurred within the 6-week window. This request is medically reasonable and 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 percutaneous vertebral augmentation (PVA) have been met. Therefore, we decided that the Plan has to pre-approve percutaneous vertebral augmentation (PVA).
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: Imaging
Decision: Favorable

We decided that the Plan has to waive one of the copayments for X-rays provided on June 17, 2021.
You asked the Plan to waive one of the copayments for the X-rays. You say that since both X-rays were
performed on the same day, there should be only one copayment. The Plan denied your request. The Plan says
that you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $20 copayment for X-rays and ultrasounds. The contract
also says that if the same service type is performed at the same session, more than once, only one copayment
will be applied.
The Plan says you must pay a $20 copayment for each set of X-rays. Based on the Plan contract, however, you
cannot be asked to pay more than one copayment if the same service type is performed in the same session.
Therefore, we decided that the Plan has to waive one of the copayments for X-rays provided on June 17, 2021.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on May 24, 2021.
You asked the Plan to pay for the ambulance response without transport. You say that the paramedics did some basic tests and told you that you were fine. You feel the bill is too high for the services provided, and you cannot afford it as you live on a fixed income. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on May 24, 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 intensive rehabilitation can give you a better quality
of life. 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 your 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral-complete series (D0210), and prophylaxis (D1110) provided by an out-of-network provider on August 4, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, intraoral-complete series, and prophylaxis. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist is out-of-network.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a
comprehensive oral evaluation (D0150), intraoral-complete series (D0210), and prophylaxis (D1110) provided by an out-of-network provider on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (75726, 36248, 99153) provided January 27, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provided records do not support the codes billed.
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 CPT code 75726, 36248, & 99153 is not supported in the medical record. Specifically, CPT 75726 has a coding conflict with another code billed and is not separately payable. The operative report does not include documentation to support selective catheter placement in additional second, third order or beyond, abdominal, pelvic, or lower extremity. CPT 36248 is not supported by the operative report. CPT 99153 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (75726, 36248, 99153) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management (99315) provided on June 29, 2021.
You asked the Plan to pay for the nursing facility discharge day management. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has an unbundling relationship with a previously paid claim and cannot be overriden by a modifier.
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 99315 is nursing facility discharge day management; 30 minutes or less. We find that CPT code 99315 is not supported in the medical record. Specifically, the record indicates that the Plan has processed and paid for another evaluation and management service which was rendered and billed by the same physician. If more than one evaluation and management service is provided on the same day to the same enrollee by the same physician, only one evaluation and management service may be reported. Based on this information, we decided that Medicare rules for coverage of the nursing facility discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility discharge day management (99315) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polarization, any lens material, per lens (V2762) provided on
July 12, 2021.
You asked the Plan to pay for polarization, any lens material, per lens. The Plan denied your request. The Plan
says sunglasses are not a covered benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine vision and
eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Medicare rules say polarization (V2762) will be denied as non-covered.
We looked at the file, the Plan's rules and the Medicare rules. The Plan says sunglasses are not covered.
Medicare says polarization (V2762) will be denied as non-covered. Therefore, we decided that the Plan does
not have to pay for polarization, any lens material, per lens (V2762) provided on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy using the ImpediMed L-
Dex device.
You asked the Plan to pre-approve the bioimpedance spectroscopy using the ImpediMed L-Dex device. You
say that you would like reconsideration because the requested service is medically necessary. The Plan denied
your request. The Plan says the clinical value and effectiveness of the requested service has not been
demonstrated in peer-reviewed literature.
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 bioimpedance spectroscopy using
the ImpediMed L-Dex device. Our reviewer says that the literature describes the use of bioimpedence
spectroscopy as a preventive measure for the development of lymphadema. Our physician reviewer found the
requested service is not medically necessary as this enrollee has not had lumpectomy, axillary node dissection,
chemo or radiation.
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 bioimpedance spectroscopy using the ImpediMed L-Dex device have not
been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy using
the ImpediMed L-Dex device.