Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are out of 
transportation benefits, and you need to see the podiatrist. The Plan denied your request. The Plan says 
additional trips would exceed your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
sixty-eight (68) one-way transportation trips out of the allowed seventy-two (72) one-way trips approved. Once 
72 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional non-emergent routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee needs daily wound care. 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 the enrollee is 
receiving weekly wound care at a wound clinic. There is no evidence that additional home-based services are 
required or that the enrollee is homebound. 
 
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 skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prostate Artery Embolization (37243). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Prostatic Arterial Embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and 
efficacy.  
  
The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside 
of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding 
radiation exposure, postembolization syndrome, vascular access, technical feasibility, and the higher clinical 
failure rate compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prostate Artery Embolization (37243).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brachioplasty and thighplasty. 
 
You asked the Plan to pre-approve a brachioplasty and thighplasty. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested procedures are cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 brachioplasty and thighplasty. Our 
reviewer says that the service is not medically necessary. Our reviewer found the record provided does not 
demonstrate the presence of intertrigo refractory to treatment or that the requested procedures are for the 
prompt repair of accidental injury or to improve the functioning of a malformed body member.  The requested 
procedures are cosmetic in nature.  
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 brachioplasty and thighplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a brachioplasty and thighplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit and arthrocentesis provided 
on November 16, 2022. 
 
You asked the Plan to waive the cost share for the office visit and arthrocentesis. You say that you had already 
met your deductible 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. Your 
contract with the Plan says that there is an $800 deductible which applies to doctor and other health care 
provider services, as well as outpatient surgery. Your contract with the plan also says that you must pay 10% 
coinsurance for in-network or out-of-network office visits. Your contract with the Plan also says that you must 
pay 10% coinsurance for in-network or out-of-network outpatient surgery. 
 
You have been asked to pay 10% coinsurance for the office visit. This item/service falls within the doctor and 
other health care provider services benefit category. You have also been asked to pay 10% coinsurance for the 
arthrocentesis. This item falls within the surgery, including services provided at hospital outpatient facilities 
benefit category. 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. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible 
which applies to doctor and other health care provider services, as well as outpatient surgery. This cost sharing 
is a contractual obligation that had not been met at the time the office visit and arthrocentesis were received on 
November 16, 2022. Therefore, we decided that the Plan does not have to waive the cost share for the office 
visit and arthrocentesis provided on November 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation (A0425). 
 
You asked the Plan to pre-approve non-emergent ambulance transportation. You say that you need to see your 
neurosurgeon. You need to be on a stretcher for medical transportation due to medical conditions. The Plan 
denied your request. The Plan says neither Medicare or your plan cover ambulance transportation to a 
physician's office or a physician directed clinic. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve non-emergent ambulance transportation 
(A0425).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment services provided on January 23, 2023. 
 
You asked the Plan to pay for the opioid treatment services. You say that you billed these services correctly. 
The Plan denied your request. The Plan says that these services must be billed on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for opioid treatment 
services provided on January 23, 2023.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary to 
optimize the level of recovery and prevent any unwarranted readmission's. The Plan denied your request. The 
Plan says the enrollee can stay in the hospital until they are safe for transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee 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 they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 25, 2022, through 
February 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that the place of service code listed is correct. 
The Plan denied your request. The Plan says that the required revenue code of 043x for occupational therapy  is 
not on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be submitted with 
certain required elements, including the correct revenue codes, HCPCS codes, and location codes.  
 
We looked at the file and Medicare rules. The claim includes revenue code 0431 which is an appropriate code 
for occupational therapy. Additionally, code Q5001 is an appropriate location code, and G0152 is an 
appropriate HCPCS code. Based on this information, we decided that Medicare rules for coverage of the home 
health services have been met. Therefore, we decided that the Plan has to pay for the home health services 
provided from February 25, 2022, through February 28, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that two of the three necessary 
elements - a detailed history and physical - are present as required by the coding definition. The history does 
not include a review of the systems, and the physical exam is quite brief. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a customized seat cushion (E2609), and a customized 
seat back (E2617). 
 
You asked the Plan to pre-approve a customized seat cushion, and a customized seat back (E2617). You say 
that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not indicated to 
have current or past skin pressure injury and the facility note agrees that the enrollee's postural issues are not 
due to fixed deformities. The past cushion systems attempted did not address the physical limitations of an 
incorrectly sized wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that customized seat cushions and customized seat backs 
can be covered when specific criteria are met. 
 
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 customized seat cushion, and a 
customized seat back (E2617). Our reviewer says that the enrollee does not meet coverage criteria. Our 
physician reviewer found the enrollee does not have a group 2 or 3 ICD 10 code for her condition nor does she 
have skin breakdown or evidence of decreased sensation. 
 
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 customized seat cushion, and a customized seat back (E2617) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a customized seat cushion (E2609), and 
a customized seat back (E2617).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and related 
accessories are not medically necessary. 
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found you have a spinal 
cord injury. You have adequate strength in your upper extremities. You do not use intermittent catheterization 
and have used a manual wheelchair for years. Since the PWC base is not medically necessary, the requested 
accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for congestive heart failure and a scrotal abscess. 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 patient 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: 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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
acute on chronic respiratory failure, COPE exacerbation, and congestive heart failure. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While 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 you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that you believe there was a claim coding error. The 
Plan denied your request. The Plan says you got the services from a provider who chose not to receive 
Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program.\ 
 
 
 
  
 Therefore, we decided that the Plan does not have to pay for an office visit provided on April 25, 2022.