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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 patient was admitted for lower extremity weakness and a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient 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 
this patient 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on September 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the most effective therapy during surgery is 
intermittent pneumatic compression therapy. The Plan denied your request. The Plan says the services were 
billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The records show that the pneumatic compression device was provided 
during services at an ambulatory surgical center. Durable medical equipment is covered when it is appropriate 
for use in the home. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device and related services provided on September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital services beginning May 11, 2022, for the 
enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that records show the enrollee does not have a severe 
worsening of chronic obstructive pulmonary disease (COPD) that did not quickly get better with treatment, 
acute respiratory failure, pneumonia, or a need for inpatient monitoring beyond scope of observation care. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The 
enrollee has a history of hypertension, high cholesterol, and chronic obstructive pulmonary disease who was 
admitted to the hospital on May 11, 2022, for shortness of breath thought to be related to a flare of your COPD. 
The record sent indicates that the enrollee received medications for the flare while in the ambulance and was 
placed on a special breathing machines (CPAP, then BiPAP) with significant improvement after treatments 
in the emergency department. He was treated with IV antibiotics and admitted. He was evaluated by 
Pulmonary. The review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. Our physician reviewer found that the 
enrollee's condition meets criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient hospital services beginning May 11, 2022, for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac surgery to be provided by an out-of-network 
(OON) provider. 
 
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 these services are 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 
cardiac surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
provided to the enrollee on November 24, 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 the code is not appropriate for the service 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. 
 
In this case, the CPT Code Manual definition of code 95941 is "Continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while 
in the operating room, per hour (List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found currently, Medicare (and its 
contractors) do not reimburse providers for CPT code 95941. This this code reflects (potential) monitoring of 
more than one procedure at a time. Rather, the CPT code accepted by the LCDs (and contractors) for this service is G0453 (which reflects monitoring just one patient at a time which is in accordance with Medicare 
regulations). As a non-covered CPT code was used, it cannot be said to have been the most appropriate code to 
use in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for continuous intraoperative neurophysiology monitoring provided to the enrollee on November 
24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal instrumentation procedures on the spine 
(vertebral column). 
 
You asked the Plan to pre-approve spinal instrumentation procedures on the spine (vertebral column). The Plan 
denied your request. The Plan says spinal instrumentation procedures on the spine (vertebral column) is 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 spinal instrumentation procedures on 
the spine (vertebral column). Our reviewer says that the requested spinal instrumentation procedures on the 
spine (vertebral column) is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review of the medical literature indicates that this service is considered experimental and 
investigational as it is not identified as widely used and generally accepted for the proposed use as reported in 
nationally recognized peer-reviewed medical literature published in the English language. The North American 
Spine Society and American Orthopedic Association do not endorse this procedure. Further, the information 
published by the manufacturer on the Vertiflex device indicates that this device is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, 
with or without back pain secondary to a diagnosis of moderate degenerative lumbar spinal stenosis. 
The FDA Summary of Safety data document describes the use of the Vertiflex device for patients with 
moderate degenerative lumbar spinal stenosis Superion InterSpinous Spacer" device is contraindicated in 
patients with severe osteoporosis. Review of the medical literature says that: "severe stenosis of greater than 
50% reduction in central canal/nerve root canal diameter often necessitates significant bony excision which 
may preclude the implantation of the Coflex or Superion," and that these devices have not been studied in 
patients with severe stenosis. The review has determined that the spinal instrumentation procedures on the 
spine at issue in this case 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 spinal instrumentation procedures on the spine (vertebral column) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve spinal instrumentation procedures on the 
spine (vertebral column) (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (U0004) provided on October 7, 2020. 
 
You asked the Plan to pay for COVID-19 testing. You say that you did not have the information you needed to 
file this claim timely. The Plan denied your request. The Plan says this claim was filed more than a year after 
the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for COVID-19 testing was not filed until October 21, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for COVID-19 testing (U0004) provided on October 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nuclear stress test provided on June 21, 2020. 
 
You asked the Plan to pay for the diagnostic service. You say that the claim was submitted on April 17, 2021. 
You say that the service should be paid. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the diagnostic service was not filed until [enter date the claim was filed]. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for nuclear stress test provided on June 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is in an acute care hospital and cannot 
stay there as long as a standard appeal takes to review. You state that the enrollee has no one at home that 
would be able to care for them and they need their antibiotics and is still on oxygen. The Plan denied your 
request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee is medically stable without any 
acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline 
and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation 
services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a buccal/labial frenectomy (D7961). 
 
You asked the Plan to pre-approve the buccal/labial frenectomy (D7961). You say that you would like the 
frenectomy to be approved under your plan. 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 
buccal/labial frenectomy (D7961).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac positron emission tomography (PET) scan 
(78433). 
 
You asked the Plan to pre-approve a cardiac PET scan. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cardiac PET scan. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that other modalities of stress testing have not been performed in the enrollee's case. Guidelines 
do not support the use of cardiac PET imaging in this role. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cardiac positron emission tomography (PET) scan (78433).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) 
vaccine rendered on August 24, 2021. 
 
You asked the Plan to pay for these services. You say that you would like the Plan to pay the entire bill. The 
Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis 
(TDaP) vaccine rendered on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteotomy (28310) provided on April 16, 2021. 
  You asked the Plan to pay for the osteotomy (28310). You say that the medical records should be reviewed for 
CPT 28310. You say that this should be payable and not denied for bundled 
services. The Plan denied your request. The Plan says CPT code 28310 is included in CPT code 28297and 
cannot be separately reimbursed. 
 
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 28310 
is a column II code to column I code 28297. 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 the osteotomy (28310) provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hearing test (92557) and hearing aid 
check (92593) provided on December 15, 2021. 
 
You asked the Plan to pay for routine hearing services. You say that you saw this provider at her previous 
practice, and you do not know any other audiologists in your area. The Plan denied your request. The Plan says 
that routine hearing services are only covered when received through the specified routine hearing vendor. The 
comprehensive hearing test is covered with a $50 copayment per your contract. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
routine hearing services only when they are provided through the specified vendor.  
 
The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 
a $50 copayment for each Medicare-covered visit for medical hearing services. 
 
We looked the file and the Plan's rules. The hearing aid check is not a Medicare-covered service, and was 
received from a provider who is not part of the Plans specified routine hearing vendor network. Based on this 
information, we decided that the Plan's rules for coverage of routine hearing services have not been met, and 
the Plan does not have to pay for the hearing aid check. 
 
You have been asked to pay a $50 copayment for the comprehensive hearing exam. The comprehensive 
hearing exam falls within the Medicare-covered visit for hearing aid services benefit category. This means you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay for the comprehensive hearing test (92557) and hearing aid check (92593) provided on 
December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 15, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service January 15, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need speech and physical therapy. You state 
you are home alone and need in service care. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found you are medically stable without any acute 
exacerbations of chronic medical problems. There are no recent documents to suggest that you are at a 
functional level that requires inpatient rehabilitation services. Admission to a SNF for inpatient skilled 
rehabilitation services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.