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

 
We decided that the Plan does not have to pre-approve  initial and follow-up office visits to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve  initial and follow-up office visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available to perform this 
service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve  
initial and follow-up office visits to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 rendered on March 20, 2023. 
 
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 criteria for CPT 99285 has not been met. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 the enrollee was sent to the 
emergency room to be evaluated for a pulmonary embolism. The testing was completed, found to be negative, 
and the enrollee was discharged. The medical decision making was not of high complexity. As such, the billing 
of CPT 99285 is not supported. 
 
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 procedure code 99285 rendered on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D3999). 
 
You asked the Plan to pre-approve the dental service (D3999). You say that you would like to request 
reconsideration of the denied dental service and that the services requested are medically necessary. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental service (D3999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (01402), injection (64447), and ultrasonic 
guidance (76942) provided on March 29, 2022. 
 
You asked the Plan to pay for the anesthesia, injection, and ultrasonic guidance. You say that the services 
should be covered. The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia, injection, and ultrasonic guidance was not filed until June 19, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the anesthesia (01402), injection (64447), 
and ultrasonic guidance (76942) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital observation services performed November 26, 
2022, through November 29, 2022. 
 
You asked the Plan to pay for the observation services. You say that the observation services should be paid as 
billed because they are supported in the record and were approved by the Plan. The Plan denied your request. 
The Plan says that the observation services are denied because an order to admit the enrollee as inpatient on 
November 26, 2023, was documented in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that when a physician orders an inpatient admission, 
but the utilization review committee determines that the level of care does not meet admission criteria, the 
hospital may change the status to outpatient when the change in status is made prior to the enrollee's discharge, 
the hospital has not submitted a claim for inpatient admission, and a physician's concurrence with the 
utilization review committee's decision is documented. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the change in status from inpatient to 
outpatient was made prior to the enrollee's discharge from the hospital on November 29, 2022. The record 
contains proof that the inpatient admission was denied by the Plan as of November 28, 2022, causing the initial 
inpatient admission order to be cancelled prior to the enrollee's discharge date. We also confirmed that the case 
file does not contain indication that a claim was submitted to Medicare for the inpatient admission. Finally, the 
case file includes documentation that the physician concurs with the utilization review committee's 
determination as it is recorded that the physican attests outpatient observational services were appropriate in 
this case. As such, the criteria have been met to change the status of the services to outpatient. Based on this 
information, we decided that Medicare rules for coverage of the observation services have not been met. 
Therefore, we decided that the Plan has to pay for the outpatient hospital observation services performed 
November 26, 2022, through November 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis provided on March 15, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that this brace is reasonable and 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation provided does not support the need for a hip orthosis. The enrollee is noted to have a diagnoses of hip arthritis on the prescription for the orthosis, but the clinical documentation 
does not indicate that the enrollee has a history of hip osteoarthritis, and the enrollee is not reporting of hip 
pain. There is also limited physical examination documentation regarding hip range of motion or potential 
instability. Therefore, the requested hip orthosis is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a hip orthosis provided on March 15, 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 you are a high risk for a fall and don't want to break 
anything. The Plan denied your request. The Plan says your condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical records 
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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 therapy sessions provided on May 3, 2023, to June 28, 2023. 
 
You asked the Plan to pay for therapy sessions. You say that you were informed that your Plan would pay for 
your therapy sessions. The Plan denied your request. The Plan says this provider is ineligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Licensed Professional 
Counselor (LPC) is among the provider types that are not eligible to enroll in Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy sessions have not been met. Therefore, we decided that the Plan does not have to pay for 
therapy sessions provided on May 3, 2023, to June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use 
other than knee (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that you will be 
having shoulder surgery and you would like the device to be covered because it will help you heal faster. The 
Plan denied your request. The Plan says CPM devices are covered only for patients who have received total 
knee replacement surgery.  
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pre-approve a continuous passive motion exercise device for use other than knee (E0936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the adjustable hospital bed purchased on 
June 1, 2022, by an OON provider.  
 
You asked the Plan to provide reimbursement for the adjustable hospital bed. You say that you called in-
network suppliers, and they did not carry the bed you needed. The Plan denied your request. The Plan says this 
item could have been provided by an in-network supplier. The Plan also says that this item was not purchased 
from a durable medical equipment supplier. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for this 
item. Therefore, we decided that the Plan does not have to provide reimbursement for the adjustable hospital 
bed purchased on June 1, 2022, by an OON provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services billed for dates of service from April 19, 2023, to 
May 10, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 has not provided a valid, clear and specific rationale for denying 
payment for the services at issue. It is the Plan's responsibility to support its denial with evidence. In this case, 
the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has to pay 
for home health services billed for dates of service from April 19, 2023, to May 10, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an 
LTACH to regain their maximum/prior level of functioning and to continue a multidisciplinary approach to 
care. The Plan denied your request. The Plan says the records do not show it is medically safe for the enrollee 
to go 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 that the enrollee would not benefit from a lateral transfer to the LTACH. The 
enrollee's needs are currently being met at the short stay hospital. The enrollee should continue to be stabilized there until ready for discharge to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you are a fall risk. The Plan denied your 
request. The Plan says you do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The records provided show that the scooter will allow you to go to 
appointments on your own. Medicare does not cover equipment for use outside the home. The records do not 
show that you have had a home assessment to show that there is adequate space for maneuvering. Based on this 
information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from February 17, 2022, 
through April 6, 2022.  
 
You asked the Plan to pay for the inpatient hospital services. You say that you are not categorized as an 
inpatient rehabilitation facility (IRF) and do not bill under IRF guidelines. The Plan denied your request. The 
Plan says that this is an IRF claim and was not billed with revenue code 0024 as required.  
 
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. We have confirmed with Medicare databases that the provider at issue is 
classified as a long-term acute care hospital (LTACH), and not an IRF. The use of revenue code 0118 to report 
room/board charges does not indicate that the services are IRF services which is the argument of the Plan. We 
find that the Plan is incorrectly applying IRF billing rules to this LTACH facility claim. Therefore, we decided 
that the Plan has to pay for the inpatient hospital services provided from February 17, 2022, through April 6, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two ankle prompts for a walker utility base. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services cannot be approved as requested. 
 
The Plan must follow Medicare rules. The rules say that other unique features of gait trainers are not separately 
payable and may not be billed with code E1399. If a supplier chooses to bill separately for a feature of a gait 
trainer that is not described by a specific HCPCS code, then code A9900 must be used. 
 
We looked at the file and Medicare rules. The file shows that the requested ankle prompts were incorrectly 
requested with code E1399. The items must be requested under code A9900. Therefore, we decided that the 
Plan does not have to pre-approve two ankle prompts for a walker utility base.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compressor (E0652) and a segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental pneumatic appliance. You 
say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a segmented, calibrated gradient PCD (E0652) is only 
covered when the individual has unique characteristics which prevent them from receiving adequate 
satisfactory pneumatic compression treatment using a nonsegmented device along with a segmented appliance 
or compression device without manual control of the pressure in each chamber. 
 
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 pneumatic compressor and a full leg 
segmental pneumatic appliance. Our reviewer says that the services are medically necessary. Our physician 
reviewer found the enrollee has lower extremity and truncal lymphedema. He has used elevation, exercise, 
compressions garments and diet modification with the addition of a standard non-calibrated compression pump, 
all of which have produced no objective improvement in his lymphedema. Objective lower extremity and trunk 
measurements are provided. Therefore, the requested segmental compression pump with calibrated gradient 
pressure (E0652) and appliance/accessory (E0667) is 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 pneumatic compressor and a full leg segmental pneumatic appliance have 
been met. Therefore, we decided that the Plan has to pre-approve a pneumatic compressor (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).  
 
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.