Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the enrollee's records do not show the need for daily skilled 
nursing services or skilled rehabilitation services. Services needed may be provided safely in a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found pain has interfered with the enrollee's response to therapy and a decision to decline 
participation in therapy due to unmanaged pain is not a basis for denial as it is an indication for daily skilled 
nursing services until pain is controlled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 a Group 2 power wheelchair (K0842) and accessories 
(E0955, E1028, E1007, E1012, E2311, E2313, E2361, E2377, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you have arthritis in your 
hands, and it is hard to get around in the wheelchair that you currently have. The Plan denied your request. The 
Plan says the requested power wheelchair and 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 that you are not at 
a high risk for skin breakdown, do not use a catheter intermittently, do not have spasticity, and do not require 
an alternative means of managing power drive controls. You have adequate upper body strength to use standard  power drives. As the power wheelchair 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 2 power wheelchair (K0842) and accessories (E0955, 
E1028, E1007, E1012, E2311, E2313, E2361, E2377, E2603).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on November 2, 2021, to 
November 17, 2021.  
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. 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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the initial 
administrative paperwork is noted, but no medical records or evaluation are identified. As such, there is 
insufficient evidence to show that home health services were medically necessary, reasonable, or provided. 
 
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 pay for the home health services provided on November 2, 2021, to November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the retainer crowns - porcelain fused to high noble metal tooth #'s 
27 and 29 (D6750). 
 
You asked the Plan to pre-approve the retainer crowns. You say that you need this bridge approved because 
you have difficulty eating hard foods without it. The Plan denied your request. The Plan says that the 
documentation did not meet the clinical criteria. 
 
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. The Plan covers the retainer 
crowns when the services are medically necessary and reasonable. 
 
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 retainer crowns. Our reviewer says 
that the services are medically necessary. Our physician reviewer found it would be beneficial for the enrollee 
to receive the bridge for teeth #'s 27, 28 and 29. It is noted that tooth #28 was approved. These procedures that 
were recommended by the enrollee's general dentist is for a 3 unit bridge. In this case the enrollee is missing 
tooth #28. Procedure codes D6750 and D6240 are used in conjunction with one another. If one of the codes is 
approved, which is the case for this enrollee, the whole bridge should be approved. Code D6240 is the 
replacement tooth for the existing missing tooth and is the connector for the adjacent teeth. Without the retainer 
crowns (D6750), it is impossible to just have the pontic replaced.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crowns have been met. Therefore, we decided that the Plan has to 
pre-approve the retainer crowns - porcelain fused to high noble metal tooth #'s 27 and 29 (D6750).  
 
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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 43261. We decided that the Plan does not have to pay for 43277.  
 
You asked the Plan to pay for procedure codes 43261 and 43277 rendered on December 30, 2022.. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 43261.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 43261 is "Endoscopic 
retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple." 
 
We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request for CPT 43261. Our reviewer says that this code is supported as a 
separately identifiable procedure. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
43261.  
 
We also decided that the Plan does not have to pay for 43277. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 43277 is "Endoscopic 
retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic 
duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct." 
 
We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request for CPT 43277. Our reviewer says that this code is not supported. 
According to CPT rules, ERCP with stent placement includes any balloon dilation performed in that duct. Only 
CPT 43276 is appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 43277 have not been met. Therefore, we decided that the Plan does not have to 
pay for 43277. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that that the enrollee needs moderate assistance to stand 
and to learn how to use their walker, so they do not bump into things. The Plan denied your request. The Plan 
says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 epidural steroid injections. Our 
reviewer says that the services are medically necessary. Our physician reviewer found there is imaging of the 
cervical spine. She has failed physical therapy and chiropractic therapy. She has clear documentation of an 
electromyography/nerve conduction velocity (EMG/NCV) showing cervical neuropathy. She meets all of the 
LCD criteria, and the request is medically reasonable and 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 epidural steroid injections have been met. Therefore, we decided that the Plan 
has to pre-approve epidural steroid injections.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show the need for daily skilled 
nursing or skilled therapy in a SNF setting. Custodial care helps with daily needs such as dressing, bathing, 
getting in and out of bed, going to the bathroom, and eating. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested hospital bed is 
medically necessary. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee does 
not have heart failure, pulmonary disease, recurrent aspiration, or indication for traction. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours for in-home support services. 
 
You asked the Plan to pre-approve the in-home support services. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested 
additional hours are over what the enrollee's benefit allows. 
 
The Plan must follow Medicare rules. The Plan contract says that in-home support services are limited to 30 
hours per year. 
 
We asked our physician reviewer to carefully review the case file to determine if the Plan was correct in 
denying the request to pre-approve the additional in-home support services. Our reviewer says that the 
supplemental benefit is not available for chronic services. Our physician reviewer found that the enrollee's 
request exceeds the contractual number of hours available. 
 
We looked at this physician's review and the file. The requested additional hours for in-home support services 
exceeds the annual 30-hour benefit. Therefore, we decided that the Plan does not have to pre-approve 
additional hours for in-home support services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are still recovering from a stroke and are 
making progress doing physical and occupational therapy. You say that you are not ready to go home because 
you are not able to transfer yourself yet. The Plan denied your request. The Plan says that a SNF admission is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you would require continued assessment by a skilled nursing and skilled therapy. 
The documentation shows that you are requiring two-person assistance with neurological deficits while making 
progress with skilled therapy. The documentation also shows that you are expected to continue to require daily 
skilled services. Therefore, you require continued daily skilled services on an inpatient basis in a skilled 
nursing 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Budesonide. 
 
You asked the Plan to pre-approve a tier exception for Budesonide. You say that the exception is needed. The 
Plan denied your request. The Plan says the items do not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Budesonide have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tier exception for Budesonide.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 rendered on April 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 the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
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 laboratory report does not 
include any documentation for support an unusual non-overlapping service for either denied codes. Infectious 
agent detection, multiple organisms, amplified probe technique was performed, which would include Candida 
species, amplified probe technique and streptococcus, group B, amplified probe technique. 
 
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 codes 87481 and 87653 rendered on April 11, 2022.