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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for your rehab 
needs. The Plan denied your request. The Plan says that you do not meet the Medicare criteria for admission to 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services (99239) provided on August 
18, 2022. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in question. 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 hospital discharge services (99239) 
provided on August 18, 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 enrollee will benefit from acute inpatient rehab 
care that cannot be accomplished at a lower level of care.  The Plan denied your request. The Plan says the 
enrollee's medical condition requires further evaluation and treatment in the acute care hospital.  
 
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 you had major back surgery and need rehabilitation 
to walk again. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve prednisone. You say that the enrollee would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that Bupivacaine, identified by CPT code J3490, is a local anesthetic, which is not separately billable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date of 
service February 9, 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 the services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that they need an intensive team 
for their 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto, Oral prescription drug non chemo (J8499).  
 
You asked the Plan to pre-approve Xarelto, Oral prescription drug non chemo. You say that is medically 
necessity for the enrollee. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto, Oral prescription 
drug non chemo (J8499).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of back pain in this enrollee is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service October 24, 
2022.   

You asked the Plan to pay for procedure code 84480. You say that you have correctly billed the services at 
issue. The Plan denied your request. The Plan says payment for code 84480 is bundled into payment for code 
84481. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 84480 billed for date of service October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional months of a home ventilator 
(E00466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that the enrollee has been using 
a ventilator since 2021 and wishes to stay with the device due to the quality of care you provide to our 
enrollees. The Plan denied your request. The Plan says the records do not show that the enrollee has failed 
BiPAP while hospitalized in the past, or that the non-invasive ventilator will not be used exclusively in AVAPS 
mode. 
 
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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD, chronic hypercarbic respiratory failure, and HFrEF with an ejection fraction of 35%. The enrollee has 
had a home ventilator since a hospitalization for hypercarbic respiratory failure in April 2021. It appears the 
enrollee's ventilatory support needs could be met with BiPAP with AVAPS and a backup rate. There is no 
evidence that this has been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. The plan has approved the ventilator for 3 months to allow 
time for transition to 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 continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) additional months of a home ventilator (E00466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Trinity allograft material during an approved 
spinal fusion surgery. 
 
You asked the Plan to pre-approve the Trinity allograft material. You say that the requested services are 
medically necessary.  The Plan denied your request. The Plan says the Trinity allograft is not proven superior 
to conventional treatments.  
 
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 Trinity allograft material. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further 
studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Trinity allograft material for an approved spinal 
procedure, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Trinity allograft material have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Trinity allograft material during an approved spinal fusion 
surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says code 99153 is 
not payable in the facility setting.  Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The file shows that the services at issue were provided in an outpatient hospital facility. We find that payment 
for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 
99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for date of service January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system, tilt only (E1002). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested seating system is 
medically necessary due to your diagnosis. The Plan denied your request. The Plan says your wheelchair has 
the ability to tilt to help protect your skin. The requested accessory is not shown as medically needed for your 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seating system, tilt only, recline only, or 
combination tilt and recline, with or without power elevating leg rests, will be covered if all criteria is met. 
 
We looked at the file and Medicare rules. The records do not show that you would be able to use a power tilt 
system. The notes do not show this as medically needed for your care. Based on this information, we decided 
that Medicare rules for coverage of a wheelchair accessory have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power seating system, tilt only (E1002).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a total hip 
arthroplasty procedure. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is a necessity for your care. The Plan denied your request. The Plan says acute inpatient hospital 
care is not medically necessary. 
 
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.   

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 hospital 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 that the provided records do not show that the admitting physician would 
reasonably expect your necessary hospital care to span two midnights. The provided records report no acute or 
unstable conditions that would require inpatient admission for the procedure; you reportedly underwent an 
uncomplicated left hip replacement in April 2023. 
 
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 hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a total hip arthroplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injections provided on December 
15, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you were misled and told 
there would be no cost at all for this procedure. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay $4.20, which 20% coinsurance of the allowed amount for code J3490 ($21 allowed 
amount x 20% coinsurance = $4.20). You have also been asked to pay $0.30, which is 20% coinsurance of the 
allowed amount for code J1020 ($1.49 allowed amount x 20% coinsurance = $0.30). These items/services fall 
within the Medicare Part B drugs benefit category. You have been asked to pay a total of $4.50 ($4.20 
coinsurance + $0.30 coinsurance = $4.50). This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the drug 
injections provided on December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G7 Sensor continuous glucose monitor (CGM) (K0554, K0553).

You asked the Plan to pre-approve the Dexcom CGM. You say that the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits.

We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand for the Dexcom CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 Sensor continuous glucose monitor (CGM) (K0554, K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment including placement 
(D6057).  
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057). You say that you went to the 
dentist for a cleaning and extraction. You say those services are routine and should be covered. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 custom fabricated abutment 
(D6057) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the custom fabricated abutment including placement (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 pay for a dental 
consultation (D9310) provided on February 8, 2023.