Persius/hicric huggingface dataset:
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 you are requesting an expedited 
reconsideration stating the enrollee is now stable and weaning and ready for LTACH transfer for continuation 
of care and ventilator weaning. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in 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 remains profoundly anemic and has acute medical issues that still 
necessitate 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63685, 63650, and 95972 for date of service 
October 20, 2022. 
 
You asked the Plan to pay for procedure codes 63685, 63650, and 95972. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are payable as billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service for procedure codes 
63685 and 63650 is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services 
when provided by one of these types of practitioners. Providers must report services with the appropriate CPT 
code. In this case, we have confirmed that code 95972 is a column II code to column I code 63650. 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 codes 
63685, 63650, and 95972 for date of service October 20, 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 meets criteria for admission. The Plan 
denied your request. The Plan says the IRF services you are requesting 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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics (E2311, E2313, E2377). We also decided 
that the Plan does not have to pre-approve a power seat elevation system (E2300).  
 
You asked the Plan to pre-approve the upgraded electronics and a power seat elevation system. You say that 
you are requesting reconsideration of the denied items. The Plan denied your request. The Plan says that the 
requested upgraded electronics are not medically necessary. The Plan also says that a power seat elevation 
system is not primarily medical in nature. 
 
We decided that the Plan has to pre-approve the upgraded electronics (E2311, E2313, E2377).   
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the upgraded electronics are medically necessary. Our physician reviewer found that you are non-
ambulatory and require a power wheelchair for mobility and performing your basic daily activities. You cannot 
adequately perform pressure relief independently and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. You also require power elevating leg rests for positioning of your 
lower extremities and lower extremity spasticity. The complexity of your seating and positioning needs 
necessitates a more complex power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the Group 3 power wheelchair base and the three power options, including, 
tilt, recline and elevating leg rests, via a joystick. 
 
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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics (E2311, E2313, E2377).  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
The Plan follows Medicare rules. Medicare rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
A power seat elevation system does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 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 pneumatic compression devices (E0676 and E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items are not covered for the prevention of deep 
vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression devices (E0676 and E0673).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that after the now approved 24 physical therapy treatments, records do 
not support that the complexity of the enrollee's conditions are such that the skills of a professional therapist 
are required to achieve further improvement in the enrollee's symptoms or functional status. Further utilization 
of the home exercise program appears appropriate at this point. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88304, 88305, 88309, 88331, 88342 and 
88341 billed for date of service December 19, 2022. 
 You asked the Plan to pay for procedure code(s) 88304, 88305, 88309, 88331, 88342 and 88341. You say that 
these services are supported in the medical record. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88304, 88305, 88309, 
88331, 88342 and 88341. This means there is both a professional and technical component for the CPT code(s). 
In this case, an appropriate modifier to indicate the professional component has not been billed with CPT 
code(s) 88304, 88305, 88309, 88331, 88342 and 88341. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88304, 88305, 88309, 88331, 88342 and 88341 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 88304, 88305, 88309, 88331, 
88342 and 88341 billed for date of service December 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care provided on July 13, 2022, to July 26, 
2022. 
 
You asked the Plan to pay for post stabilization care. You say that the whole stay was medically necessary. The 
Plan denied your request. The Plan says this stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that plans do not have to pay for non-plan care except for 
emergencies, out-of-area urgently needed care, post-stabilization care and pre-approved care.   
 
The record shows that the enrollee was stable for transfer as of July 20, 2022. Once the enrollee was deemed 
stable for transfer, the emergency ended. This means that post stabilization care was not provided in an 
emergency. The inpatient care also did not involve out-of-area urgent care services and it was not pre-
approved. Therefore, we decided that the Plan does not have to pay for post stabilization care provided on July 
13, 2022, to July 26, 2022.  
 
The original decision letter was amended to include the correct dates of service for dismissal.
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. The Plan 
denied your request. The Plan says the enrollee does not meet all the required Medicare criteria for admission 
to an inpatient rehabilitation facility. 
 
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 is deconditioned with a history of prior functional impairment. The 
enrollee can walk with stand by assist. The enrollee does not require intensive or complex rehabilitation 
services. There is no indication for frequent physiatry oversight. The services are 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary as you are a fall 
risk and need additional therapy. The Plan denied your request. The Plan says while you will likely benefit 
from ongoing therapy to enhance rehabilitation potential, there is no evidence that this cannot safely be done 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 you are past the acute phase of your stroke. You have experienced little neurological 
recovery in your right arm. You do not require intensive stroke rehabilitation. Your persistent neurological 
deficit impairs your capacity to respond to intensive rehabilitation services. There is no complex rehabilitation 
need or no indication for frequent physiatry oversight. IRF criteria is not met. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the member needs this item. The Plan denied 
your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on March 1, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room services provided on 
March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D1330). 
 
You asked the Plan to pre-approve the dental service (D1330). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service (D1330) 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 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 (D1330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve the item. You say that the enrollee's current prosthesis is ill-fitting and 
causing pain during use. The Plan denied your request. The Plan says there are not enough studies to show 
vacuum socket is safe and effective for the enrollee's condition. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the VASS at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided records from the enrollee's treating 
physician in this case do not document any need for the requested VASS. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted socket system (VASS) (L5781).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment of rosacea. 
 
You asked the Plan to pre-approve laser treatment of rosacea. You say that laser treatment of rosacea is 
medically necessary. The Plan denied your request. The Plan says that laser treatment of rosacea is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laser treatment of rosacea. Our reviewer 
says that the requested laser treatment of rosacea is considered medically necessary in this case. Our physician 
reviewer found based on community standards of care laser treatment of rosacea is medically necessary. The 
you have erythematotelangiectatic rosacea that failed the 1st line medication.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser treatment of rosacea have been met. Therefore, we decided that the Plan 
has to pre-approve laser treatment of rosacea.  
 
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: Favorable

 
We decided that the Plan has to pay for remote neuromonitoring provided on December 5, 2022. 
 
You asked the Plan to pay for remote neuromonitoring. You say that the remote neuromonitoring was 
medically necessary. The Plan denied your request. The Plan says that the requested remote neuromonitoring 
was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for remote neuromonitoring. Our reviewer says 
that the requested remote neuromonitoring is considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee underwent a multi-level procedure involving the cervical 
spine. The provision of neuromonitoring during such surgery is well supported within current literature and is 
otherwise reflective of the standards of practice/care in the community. Code G0453 under review is reflective 
of the monitoring physician's services (monitoring) the surgery. Given that the services provided were 
consistent with standards of practice/care and were otherwise appropriate, code G0453 would be 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 remote neuromonitoring have been met. Therefore, we decided that the Plan has 
to pay for remote neuromonitoring provided on December 5, 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.