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

 
We decided that the Plan has to pre-approve the electronic connection device (E2311). 
 
You asked the Plan to pre-approve the electronic connection device. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says that that it is not medically necessary to 
control the power tilt option through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connection device is covered when it is 
medically necessary to control the power options through the joystick. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the electronic connection device. Our 
reviewer says that the electronic connection device is medically necessary. Our physician reviewer found that 
the enrollee is functionally non-ambulatory and requires a power wheelchair for mobility and performing her 
basic daily activities. The enrollee cannot perform pressure relief independently due to weakness and 
rheumatoid arthritis and requires a power wheelchair with power tilt for adequate pressure relief and 
positioning. The enrollee also requires power elevating leg rests given her lower extremity lymphedema. The 
electronic connection is necessary to operate the Group 2 power wheelchair base and the power options, 
including tilt and elevating leg rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electronic connection device have been met. Therefore, we decided that the 
Plan has to pre-approve the electronic connection device (E2311).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for phlebotomy services (code 99195) billed for date of service 
September 16, 2021. 
 
You asked the Plan to pay for the phlebotomy services. You say that you have provided documents showing 
that these services were provided. The Plan denied your request. The Plan says the claim for this date of service 
was not timely filed. 
 
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 phlebotomy services was not filed until December 8, 2022. 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 phlebotomy services (code 99195) billed for date of service 
September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation with a medicinal agent (D4921 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and your provider is 
recommending these services. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan.  

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 pre-approve 
gingival irrigation with a medicinal agent (D4921 x 4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee has had 
a decline from their baseline level of function and would likely benefit from occupational therapy and physical 
therapy but does not require the intensity of therapies provided on acute inpatient rehabilitation. Therefore, the 
IRF admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose monitor and supplies provided on October 
19, 2022. 
 
You asked the Plan to pay for the monitor and supplies. The Plan denied your request. The Plan says the claim 
is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the 
etiology code, and a code first note at the manifestation code. These instructional notes indicate the proper 
sequencing order of the codes, etiology followed by manifestation.   
We looked at the file and Medicare rules. The record shows that the claim was billed with primary diagnosis 
code E08.42. This code has a code first note, which means it is a manifestation code and must be sequenced 
after an etiology code. Based on this information, we decided that Medicare rules for coverage of the monitor 
and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the blood glucose 
monitor and supplies provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 10, 2022.

You asked the Plan to pay for procedure code 81345. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, we have confirmed that code 81345 is a column II code to column I code 0089U. CPT code 81345 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the retainer crown - porcelain fused to noble metal tooth #'s 18, 29 
and 31 (D6752). We also decided that the Plan does not have to pre-approve pontic - porcelain fused to noble 
metal tooth #'s 19, 20.  
 
You asked the Plan to pre-approve pontic - porcelain fused to noble metal tooth #'s 19, 20 and 30 (D6242), and 
retainer crown - porcelain fused to noble metal tooth #'s 18, 29 and 31 (D6752). You say that you are a patient 
with an immune condition with psoriasis, arthritis, diabetes which affects your dental health. You also say that 
you need attention for the approval of the missing work for economic reasons you cannot afford.  The Plan says 
the crown services requested by your provider are denied because you have reached your maximum coverage 
amount for these services. 
 
We decided that the Plan has to pre-approve the retainer crown - porcelain fused to noble metal tooth 
#'s 18, 29 and 31 (D6752).   
 
The Plan has not substantiated their denial reason. They have not provided evidence that the benefit for retainer 
crowns has been exhausted. The documentation shows that the authorization previously issued for these 
services has expired, and that the services were never received by the enrollee. Therefore, we decided that the 
Plan has to pre-approve the retainer crown - porcelain fused to noble metal tooth #'s 18, 29 and 31 (D6752).  
 
Therefore, we decided that the Plan has pre-approve the retainer crown - porcelain fused to noble metal tooth 
#'s 18, 29 and 31 (D6752).  
 
We also decided that the Plan does not have to pre-approve pontic - porcelain fused to noble metal tooth 
#'s 19, 20. 
 
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, certain limitations apply. The record 
shows your benefit for the pontic  porcelain tooth #s 19 and 20 benefit is exhausted now that the Plan has 
been told to pre-approve 3 units of D6752 and has already pre-approved 1 unit of D6242. Therefore, we 
decided that the Plan does not have to pre-approve the pontic  porcelain tooth #s 19 and 20.  
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the Plan's denial. The Plan denied 
your request. The Plan says the requested IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
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 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary as you have 
difficulty getting around. The Plan denied your request. The Plan says your needs could be met at a lower level 
of 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 do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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.
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 services are necessary to meet the rehabilitation 
needs of the enrollee. 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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.
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 the IRF care is not medically necessary, and the enrollee's 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 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 was admitted for surgical repair of a hip fracture after a fall. 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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON skilled nursing facility services. You say that you want to go to an 
out-of-network facility because that is where your partner currently resides. The Plan denied your request. The 
Plan says skilled nursing facility care is available at in-network facilities. 
 
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 
skilled nursing facility services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services.  
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that in this 
case, the documentation doesnt support that you require additional skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or rehab 
services to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health 
services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has been responsive to 
TMS therapy. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee had completed 32 sessions. The enrollee does not meet the clinical criteria for 
the use of TMS as she has had a recent Personal Health Questionnaire Depression Scale (PHQ-9) score of 9 on 
May 3, 2023, and a previous PHQ 9 score of 14 on March 6, 2023, which does not meet the demonstrated 
criteria of a 50% or greater improvement. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transcranial magnetic stimulation (TMS) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. The enrollee reportedly has bilevel positive airway pressure (BiPAP) at home, for an unknown 
duration and unknown compliance. This enrollee may benefit from attention to home BiPAP settings and 
compliance. There is no documentation of failure of home BiPAP. Medicare does not cover a home ventilator 
in the treatment of obesity hypoventilation syndrome (OHS), or when used at settings that can be provided with 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.