Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient level of care. 
 
You asked the Plan to pre-approve acute inpatient level of care. You say that this is medically necessary. The 
Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The 
Plan also says there is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. 
 
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 acute inpatient level of care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided documentation does not describe the enrollee with an unstable 
condition or at high-risk status to expect a need for hospital services that will likely cross 2 midnights 
following this typically ambulatory procedure. Therefore, the reviewer found that the inpatient level of care 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 acute inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you have some swelling at your surgical 
site that needs to be checked out. You say that you do not have an extension with trip mileage with Medicaid 
and there are no helpful area resources that will assist you with not missing your medical appointment. The Plan denied your request. The Plan says additional mileage beyond what is allowed by the benefit is not 
covered. 
 
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 routine transportation when a one-way trip must not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the record shows 
that the requested trip is more than 50 miles of driving distance. Therefore, we decided that the Plan does not 
have to pre-approve additional mileage.
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 enrollee needs inpatient rehabilitation and 
disagrees with the denial. The Plan denied your request. The Plan says the enrollee's condition does not meet 
the Medicare guidelines.  The Plan says that the services needed may be provided safely in 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 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3-R MIS Fusion Plate. 
 
You asked the Plan to pre-approve the Minuteman device. You say that this should be approved. The Plan 
denied your request. The Plan says this 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 the Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Minuteman device is considered experimental. Therefore, the reviewer found 
that the requested Minuteman device 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman G3-R MIS Fusion Plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 3, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that the treating 
physician determined this testing was medically necessary. The Plan denied your request. The Plan says 
ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical 
management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there 
was no indication to perform definitive testing. There is no documentation of early refills, suspected diversion 
or abuse and no abnormal screening labs. The testing was not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on April 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 93005, defined as routine electrocardiogram with at least 12 
leads; tracing only, without interpretation and report, performed on date of service March 10, 2023. 
 
You asked the Plan to pay for 93005. You say that 93005 should be covered because it was medically 
necessary. The Plan denied your request. The Plan says 93005 is denied because it has a status indicator of Q1, 
indicating it is an STV-packaged code, and it was billed on the same claim as 99285, which has a status 
indicator of V.  
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are assigned a status 
indicator of Q1. STV-packaged services are not eligible for separate payment when a service with status indicator S, T, or V is reported on the same claim. 
 
We looked at the file and Medicare rules. We confirmed that 93005 has a status indicator of Q1, so it is an 
STV-packaged service. We confirmed 99285 has a status indicator of V and was billed on the same claim. 
Therefore, no separate payment is warranted for 93005. Based on this information, we decided that Medicare 
rules for coverage of 93005 have not been met. Therefore, we decided that the Plan does not have to pay for 
93005, defined as routine electrocardiogram with at least 12 leads; tracing only, without interpretation and 
report, performed on date of service March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliance (E0669). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the records does not show lymphedema extending onto 
the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show lymphedema extending onto 
the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0652) and segmental appliance (E0669).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided May 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. 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 the outpatient intravenous (IV) insulin therapy (OIVIT) services provided May 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-
aided field setting, simple (77280), therapeutic radiology simulation-aided field setting, complex (77290). 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy, skin surface application, per 
fraction, includes basic dosimetry, when performed, therapeutic radiology simulation-aided field setting, 
simple, therapeutic radiology simulation-aided field setting, complex. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient data to support the routine use of this type of 
superficial radiation treatment of squamous cell carcinoma. 
 
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 high dose rate electronic brachytherapy, 
skin surface application, per fraction, includes basic dosimetry, when performed, therapeutic radiology 
simulation-aided field setting, simple, therapeutic radiology simulation-aided field setting, complex. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are insufficient long-term efficacy and safety data to support the 
routine use of electronic surface brachytherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high dose rate electronic brachytherapy, skin surface application, per fraction, 
includes basic dosimetry, when performed, therapeutic radiology simulation-aided field setting, simple, 
therapeutic radiology simulation-aided field setting, complex have not been met. Therefore, we decided that the 
Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface application, per 
fraction, includes basic dosimetry, when performed (0394T), therapeutic radiology simulation-aided field 
setting, simple (77280), therapeutic radiology simulation-aided field setting, complex (77290).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued inpatient psychiatric admission from 
September 8, 2023, forward. 
 
You asked the Plan to pre-approve the continued inpatient psychiatric admission. You say that the enrollee has 
a history of inpatient hospitalizations and suicidality and is considered high risk. The Plan denied your request. 
The Plan says criteria is not met. 
 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 the continued inpatient psychiatric 
admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
based upon review the records provided, this patient does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of September 8, 2023 forward and could have 
been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and 
compliant while not showing any acute threats to safety. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continued inpatient psychiatric admission from 
September 8, 2023, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 76937. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not supported in the medical records. 
 
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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (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 procedure code 76937. Our reviewer says that this code is 
not supported as billed. Our reviewer found this procedure was not included in the documentation and therefore 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76937 billed for date of service April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is high-risk for bleeding. 
The Plan denied your request. The Plan says the enrollee has not met the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous left atrial appendage closures are 
only covered under certain medical indications. 
 
 
 We looked at the file and Medicare rules. The records do not show that the enrollee is enrolled in a covered 
registry. 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 a percutaneous left atrial 
appendage closure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7140 and D7210) for tooth #5, #6, #7, 
#8, #9, #10, #13, #14, #23, #24, #25, #26, and #27 and to pay for the intraoral radiographic image (D0230), the 
immediate upper denture (D5130), and the immediate lower denture (D5140) provided by an out-of-network 
provider on December 15, 2022, and January 30, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reimburse you 
the $5,000 for the dental services. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Also, the intraoral radiographic image, the immediate upper denture, and the immediate lower 
denture were not covered by the Plan in 2022. 
 
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. 
 
For each of the extractions (D7140) the total amount billed for 1 extraction was $180 and the total allowed 
amount was $60 leaving a difference of $120 ($180 billed - $60 allowed). There was a total of 12 extractions 
(D7140) with a total difference amount of $1,440 ($120 difference x 12 extractions). The total amount billed 
for the extraction (D7210) was $275 and the total allowed amount was $118 leaving a difference of $157 ($275 
billed - $118 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
intraoral radiographic image, the immediate upper denture, and the immediate lower denture were not covered 
under the Plans 2022 benefit. Therefore, we decided that the Plan does not have to pay more for an extraction 
(D7140 and D7210) for tooth #5, #6, #7, #8, #9, #10, #13, #14, #23, #24, #25, #26, and #27 and to pay for the 
intraoral radiographic image (D0230), the immediate upper denture (D5130), and the immediate lower denture 
(D5140) provided by an out-of-network provider on December 15, 2022, and January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12031 billed for date of service May 12, 
2023. 
 You asked the Plan to pay for procedure code 12031. The Plan denied your request. The Plan says payment for 
code 12031 is bundled into payment for code 21555. 
 
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 12031 
is a column II code to column I code 21555. 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 12031 billed for date of 
service May 12, 2023.
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 admission is medically necessary for you. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines.  The Plan 
says that the services needed may be provided safely in 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 enrollee is not at baseline of recovery and needs 
physical and occupational therapy to regain function. The Plan denied your request. The Plan says the 
enrollee's records do not show to have complex medical needs and require to be seen by a rehabilitation 
physician. The Plan says that the services needed may be provided safely in 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 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.  
 
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.