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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does 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 the enrollee was admitted for gastrointestinal bleeding. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemical agent (gallium) (A9596) 
used in connection with a diagnostic imaging service provided on January 24, 2023. 
 
You asked the Plan to waive the coinsurance for the chemical agent used for imaging. You say that you have 
already paid your $110 copayment for the imaging service and should not owe an additional amount. 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 each Medicare-covered medical supply. The rules say that supplies for which an appropriate 
separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are 
subject to separate cost-sharing. 
 
You have been asked to pay 20% coinsurance for the chemical agent used for imaging. This item/service falls 
within the Medicare-covered medical supply benefit category. There is a separate cost-share for this service 
because it is an appropriate separate charge for a chemical agent used in a diagnostic procedure. 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 chemical agent (gallium) (A9596) used in connection with a 
diagnostic imaging service provided on January 24, 2023.
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 admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 enrollee was admitted with altered mental status in the setting of acute hypoxic 
respiratory failure secondary to parapneumonic effusion. The record indicates that the enrollee has ongoing 
acute medical issues and still requires acute care services. 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. The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat wireless capsule endoscopy.  
 
You asked the Plan to pre-approve a repeat wireless capsule endoscopy. You say that the enrollee's medical 
condition requires further testing for possible treatment.  The Plan denied your request. The Plan says the 
records do not show any documentation as to why it would be medically necessary to perform a third capsule 
endoscopy in the span of 13 months. 
 
The Plan follows Medicare rules. Medicare rules say that repeat wireless capsule endoscopic studies are 
covered when medical records demonstrate it is medically reasonable and necessary for clinical circumstances 
consistent with accepted standards of medical practice. 
 
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 repeat wireless capsule endoscopy. 
Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee 
has stable hemoglobin and normal iron levels. There is no indication for a repeat wireless capsule endoscopy, 
and 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 a repeat wireless capsule endoscopy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a repeat wireless capsule endoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis (L1950). 
 
You asked the Plan to pre-approve an ankle foot orthosis. You say that this brace is medically necessary. The 
Plan denied your request. The Plan says a custom orthosis exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that for a custom fabricated orthosis (L1950), there must 
be detailed documentation in the treating practitioner's records to support the medical necessity of custom 
fabricated rather than a prefabricated orthosis. 
 
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 an ankle foot orthosis. Our reviewer 
says that the requested orthosis is not medically necessary. Our physician reviewer found while the records support the need for stabilization, the records do not document why a prefabricated orthosis is insufficient to 
meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle foot orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ankle foot orthosis (L1950).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428-PN, -NP), and ground mileage (A0425-PN, -NP) provided on March 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you were in a rehabilitation facility when 
you needed to be transported to your appointment. You also say that you feel this should be covered. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that because the service is covered and payable as a 
beneficiary transportation service under Part A, the service cannot be classified and paid for as an ambulance 
service under Part B.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428-PN, -NP), and ground 
mileage (A0425-PN, -NP) provided on March 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the ankle. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no trial of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has Achilles tendon pain. The record provided is insufficient to support the 
medical necessity of the requested service and does not document the failure of conservative treatment or red 
flag signs or symptoms.  The requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not 
satisfied. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the ankle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. You say that you do not have 
enough strength in your right hip, you have arthritis in your back, and your hips and knees are very bad. The 
Plan denied your request. The Plan says you were previously authorized for a heavy-duty walker on May 24, 
2023. The Plan also says that there is no documentation that you meet all of the Medicare coverage criteria 
requirements. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 group 1 heavy duty power operated 
vehicle. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found has a 
personal mobility deficit, but it is not clear that this deficit impairs participation in MRADLs and is unable to 
be helped by a walker. Our reviewer also found that the documentation does not reveal evidence of a home 
evaluation indicating that the requested group 1 heavy duty power operated vehicle (K0801) can be safely 
maneuvered in the home. 
 
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 group 1 heavy duty power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801).
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 requesting an expedited reconsideration as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the service requested 
is not supported based on the records received.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 procedure codes 96365-59, 96366-59, and 96521 provided 
on March 29, 2023. 
 
You asked the Plan to pay for procedure codes 96365-59, 96366-59, and 96521. You say that the medical 
records support the billing of codes 96365, 96366, and 96521.  The Plan denied your request. The Plan says the 
medical records do not support the billing of codes 96365, 96366, and 96521.  
 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 96365 is Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is Refilling and 
maintenance of portable pump. 
 
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 codes 96365-59, 96366-59, and 96521. Our 
reviewer says that the medical records do not support the billing of codes 96365, 96366, and 96521.  Our 
reviewer found procedure code 96365 is not supported. The procedure report documents "Restor Metabolix 
uses the Nimbus Portable Infusion Pump.  Novolin R with Saline is used for the treatment of Pre-diabetes, 
Type 1 Diabetes, Type 2 Diabetes, and Metabolic Syndrome".  In this case, service denied correctly, as the 
incorrect code was reported for the service documented.  There is a more appropriate code to report for the 
services documented. 
 
Procedure code 96366 is not supported. The procedure report documents "Restor Metabolix uses the Nimbus 
Portable Infusion Pump.  Novolin R with Saline is used for the treatment of Pre-diabetes, Type 1 Diabetes, 
Type 2 Diabetes, and Metabolic Syndrome".  In this case, service denied correctly, as the incorrect code was 
reported for the service documented.  There is a more appropriate code to report for the services documented.  
Of note, this procedure would not be inclusive to CPT 96365 when reported correctly, however, this code is not 
supported in documentation submitted. 
 
Procedure code 96521 is not supported. The medical record does not include documentation of a refilling and 
maintenance of portable pump, and therefore cannot be verified.  Unable to cite report, as this procedure was 
not found in the documentation submitted. 
 
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 codes 96365-59, 96366-59, and 96521 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 96365-59, 96366-59, and 96521 provided on 
March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhytidectomy provided on February 23, 2023.  
 
You asked the Plan to pay for the rhytidectomy. You say that the surgery was medically necessary. The Plan 
denied your request. The Plan says the requested rhytidectomy is not medically necessary and is cosmetic.  
 
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 pay for the rhytidectomy. Our reviewer says that the 
requested rhytidectomy is not considered medically reasonable and necessary. Our physician reviewer found 
that the record indicates that you underwent a procedure on your eyelids. The record provided does not 
establish the medical necessity of the requested procedure nor does it document the performance of the billed 
procedure. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 rhytidectomy have not been met. Therefore, we decided that the Plan does 
not have to pay for a rhytidectomy provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve CGM. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the record does not show that the enrollee is on insulin treatment or has a 
history of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM. Our reviewer says that the 
enrollee does not meet criteria for a CGM. Our physician reviewer found the office note from May 30, 2023 
does not support either low blood glucose or insulin use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 18, 
2023. 
 You asked the Plan to pay for procedure code 87150. The Plan denied your request. The Plan says payment for 
code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 18, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee often uses a manual wheelchair 
and is in need of an electric scooter for public ambulation as his wheelchair is too heavy for him or his wife to 
lift into the car given their disabilities. The Plan denied your request. The Plan says Medicare does not provide 
a POV that is needed for use only outside the 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 a power operated vehicle (POV) (K0800).