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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID infection and weakness. The enrollees 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 medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiological examination of the knee (73564) provided on 
March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a radiological examination of the knee. You say that you want the Plan to 
reconsider for payment. The Plan denied your request. The Plan says the provider is out-of-network, and 
authorization was not obtained prior to the services being rendered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a radiological examination of the knee (73564) 
provided on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that it is not reasonable to expect that you will be able to safely 
participate in, or fully benefit from, the intensity of services of an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Non-traumatic spinal 
cord injury/radiculopathy is an IRF compliant diagnosis. Clinical documentation shows you have active 
comorbidities which would require close medical monitoring on an inpatient basis. Evaluating therapists in 
multiple disciplines state that you would tolerate and significantly benefit from intense therapy. Our physician 
reviewer found that your condition meets Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee has multiple 
comorbidities and was hospitalized for altered mental status secondary to presumed Lewy Body dementia. The 
records document functional impairments; however, neurology documents that the impairments are secondary to an irreversible cause (Lewy Body dementia). The records do not support that the enrollee would make a 
clinically significant benefit from therapy in an IRF. The services are therefore not reasonable or 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 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: Favorable

 
We decided that the Plan has to pre-approve transcervical uterine fibroid(s) ablation with ultrasound guidance, 
radiofrequency (0404T). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the procedure is medically necessary. 
 The Plan denied your request. The Plan says that this type of procedure is considered experimental / 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 radiofrequency ablation. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the fibroid is reportedly causing cramping every day with pelvic pressure. The 
enrollee has failed medical management, and the pain "is significantly impacting her life and causing her 
depression to be worse". The clinical documentation supports that the proposed transcervical radiofrequency 
ablation is medically reasonable and necessary for the enrollee in this case. The procedure has been shown to 
provide significant clinical improvement through 3 to 5 years of follow-up, with a low incidence of surgical 
reintervention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have been met. Therefore, we decided that the Plan has 
to pre-approve transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency (0404T).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous platelet rich plasma (PRP) for non-diabetic 
chronic wounds/ulcers. 
 
You asked the Plan to pre-approve the autologous PRP. You say that you would like reconsideration because 
the requested PRP is medically necessary. The Plan denied your request. The Plan says the requested PRP is 
not covered because the enrollee does not have diabetes. 
 
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 autologous PRP. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found PRP application once a week promotes the healing of chronic ulcers. Its effect on 
ulcer area seems to be nonsignificant. However, larger comparative series are still needed to confirm these 
findings. 
 
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 autologous PRP have not been met. Therefore, we decided that the Plan 
does not have to pre-approve autologous platelet rich plasma (PRP) for non-diabetic chronic wounds/ulcers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens 
(V2781), lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass (V2783), and 
vision supply, accessory and/or service component (V2797) provided on December 1, 2021. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lens, lens, and vision supply, accessory 
and/or service component. You say that it is not your fault that you were misquoted at the vision center. The 
Plan denied your request. The Plan says additional upgrade options are explicitly listed as not covered in the 
2021 Evidence of Coverage. 
 
 
 Medicare generally does not cover routine vision and 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. The Plan covers standard single vision, lined bifocal, lined trifocal, lenticular, and standard 
progressive lenses. 
 
We looked at the file and the Plan's rules. The contract said to contact the Plan for a list of additional options 
you could purchase for your eyeglass lenses and contact lenses. You received additional lens options. Based on 
this information, we decided that the Plan's rules for coverage of the anti-reflective coating, progressive lens, 
lens, and vision supply, accessory and/or service component have not been met. Therefore, we decided that the 
Plan does not have to pay for the anti-reflective coating (V2750), progressive lens (V2781), lens, index greater 
than or equal to 1.66 plastic or greater than or equal to 1.80 glass (V2783), and vision supply, accessory and/or 
service component (V2797) provided on December 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation trips. You say that you require transportation. The 
Plan denied your request. The Plan says that this is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
necessary due to having psychosis. The Plan denied your request. The Plan says that your condition has 
improved and is no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active 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 pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation, 
auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to 
safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others and 
was compliant with your treatment. Our physician reviewer found that your condition does not meet 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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 the records show that the enrollee does not have complex needs and does not require frequent physiatry oversight. The physical therapist has recommended subacute rehabilitation. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifty (50) additional routine transportation trips. 
 
You asked the Plan to pre-approve fifty (50) additional routine transportation trips. You say that you need 
additional transportation rides for your appointments. The Plan denied your request. The Plan says that the 
requested amount exceeds the Plan limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation trips above the benefit maximum of sixty (60) 
routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve fifty (50) 
additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery services provided on October 3, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure note supports the code. The 
Plan denied your request. The Plan says the services were not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the enrollee was an inpatient at the time CPT code 62252 was provided. Medicare rules say that 
CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The 
facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers. This service was provided via arrangement of the facility. Payment for this 
service would have been included under the facility claim.  Payment to you for this service is the responsibility of the facility. 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 surgery services provided on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93285 billed for date of service March 24, 
2022. 
 You asked the Plan to pay for procedure code 93285. You say that you have provided medical records to 
support the service billed. The Plan denied your request. The Plan says payment for code 93285 is bundled into 
payment for code 33285. 
 
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 93285 
is a column II code to column I code 33285. 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 93285 billed for date of service March 24, 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 the records should support the necessity of the 
services. The Plan denied your request. The Plan says admission to AIR or IRF was denied as not meeting the 
criteria, not medically necessary, and a lower level of care might be appropriate. SNF level of care was offered. 
 
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 enrollee 
was admitted for rib and thoracic fractures after a fall. 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 medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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.