Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that you need this item for travel. 
The Plan denied your request. The Plan says there is no evidence you are using oxygen in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the portable oxygen concentrator (E1392).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can get met at a lower level of care such as a skilled nursing facility (SNF) care. 
 
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 enrollee's medical problems are stable, and 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. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under CMS guidelines. You say that the enrollee requires prolonged and intensive skilled 
services that are not available at a lower level of care. The Plan denied your request. The Plan says 
authorization denied because the LTACH is not medically necessary, and the enrollee's needs can be met at a 
lower level of care when they are stable for transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee requires ongoing acute care services before being able to transition to a lower level of care. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retrobulbar injection (67500) provided on December 14, 
2021. 
  You asked the Plan to pay for the retrobulbar injection (67500). The Plan denied your request. The Plan says 
the documents received do not support that the service was distinct or independent from other services 
performed. 
 
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 67500 is a column II code to column I code 67028; however, 67500 
was billed with a modifier.  
 
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 retrobulbar injection (67500). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report describes a Lidocaine injection and Avastin injection in the same anatomical site. In this case, 
this procedure would be inclusive to CPT code 67028. 
 
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 retrobulbar injection (67500) have not been met. Therefore, we decided that 
the Plan does not have to pay for the retrobulbar injection (67500) provided on December 14, 2021.
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 LTACH is medically necessary and 
the enrollee meets LTACH admission criteria. You say that the LTACH is necessary to achieve a safe and 
sustainable discharge. The Plan denied your request. The Plan says authorization denied because the LTACH is 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as inpatient 
rehabilitation facility or a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee requires ongoing acute care services before 
being able to transition to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a therapeutic, prophylactic, or 
diagnostic injection (96372), a ceftriaxone sodium injection (J0696) and a methylprednisolone acetate injection 
(J10440) provided on November 23, 2021. 
 
You asked the Plan to pay an additional amount for injections. You say that your office is expecting separate 
reimbursement for the injections. The Plan denied your request. The Plan says the servicing provider is a RHC 
and the provider gets a flat rate payment for all services performed per date of service. 
 
The Plan must follow Medicare rules. The rules say that per visit payment and exceptions under the AIR, 
RHCs and FQHCs are paid an AIR per visit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of injections have not been met. Specifically, the provider gets a flat rate payment for all services 
performed per date of service. The injections are included in the AIR that was already paid to the provider. 
Therefore, we decided that the Plan does not have to pay an additional amount for a therapeutic, prophylactic, 
or diagnostic injection (96372), a ceftriaxone sodium injection (J0696) and a methylprednisolone acetate 
injection (J10440) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on January 20, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home-delivered meals (S5170). 
 
You asked the Plan to pre-approve the home-delivered meals. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the records determine the diagnosis on the hospital 
discharge is not on the Plan's list of Congestive Heart Failure diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may choose to offer some benefits to 
enrollees in addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits they are 
required to offer.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home-delivered meals have not been met. Specifically, the Plan covers this service after 
congestive heart failure; your diagnosis does not meet this criteria. Therefore, we decided that the Plan does not 
have to pre-approve the home-delivered meals (S5170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently receiving physical therapy in order 
to gain enough strength for more intense therapy. You say you need rehabilitation to get better so you can 
continue his life. The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and you needs can be met at a lower level of care such as a skilled nursing facility (SNF) 
care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH service prescribed is 
covered under the plan and is medically necessary. The Plan denied your request. The Plan says authorization 
because the LTACH is not medically necessary, and your needs can be met at a lower level of care such as a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you require ongoing acute care services before being able to transition to a lower 
level of care. You continue to receive acute care services, and these have not been denied. The medical record 
does not indicate that you require services that you are not currently receiving but that would be available at the 
LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on October 23, 2021, have been met. In this case, no medical records were provided for review. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional resin-based composite (D2330) and 
endodontic therapy (D3310) provided on October 5, 2021. 
 
You asked the Plan to pay for the additional resin-based composite (D2330) and endodontic therapy (D3310). 
You say that the dental office never informed you during the procedure about the plan approval for treatment 
and the cost of it. You say that you need the dental plan to cover this bill. The Plan denied your request. The 
Plan says you exceeded the $1,000 allowance. 
 
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, you also have a maximum benefit of 
$1,000 every year for covered dental services. The Plan paid $874 toward the dental services provided on this 
date, which exceeded your $1,000 allowance. Therefore, we decided that the Plan does not have to pay for the 
additional resin-based composite (D2330) and endodontic therapy (D3310) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a handheld shower wand and a sock puller. 
 
You asked the Plan to pre-approve a handheld shower wand and a sock puller. You say that these items are 
necessary for your condition. The Plan denied your request. The Plan says these items are not covered as they 
are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a handheld shower wand and a sock puller.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intra-Dialytic Parenteral Nutrition. 
 
You asked the Plan to pre-approve Intra-Dialytic Parenteral Nutrition. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member is able to take food and fluids orally and 
the malnourishment is not due to malabsortion. 
 
The Plan must follow Medicare rules. Medicare rules say that for parenteral nutrition to be considered 
reasonable and necessary, the treating practitioner must document that enteral nutrition has been considered 
and ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The 
beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands which 
significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. The beneficiary must have a permanent impairment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Intra-Dialytic Parenteral Nutrition have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Intra-Dialytic Parenteral Nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intra-Dialytic Parenteral Nutrition. 
 
You asked the Plan to pre-approve the Intra-Dialytic Parenteral Nutrition. You say that the service is medically 
necessary. The Plan denied your request. The Plan says documentation indicated the enrollee is able to tolerate 
an oral diet and malnourishment is not related to a malabsorptive state. 
 
The Plan must follow Medicare rules. Medicare rules say that for parenteral nutrition to be considered 
reasonable and necessary, the treating practitioner must document that enteral nutrition has been considered 
and ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The 
beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands which 
significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. The beneficiary must have a permanent impairment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intra-Dialytic Parenteral Nutrition have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Intra-Dialytic Parenteral Nutrition.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services on November 17, 2021. 
 
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
to attend your medical appointments. The Plan denied your request. The Plan says the benefit for routine 
transportation is exhausted. 
 
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 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.