Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to an IRF to regain your strength. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, but skilled therapies 
as an outpatient or at a skilled nursing facility (SNF) may be approved upon request.  
 
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. Your medical problems 
are stable and 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: 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 services are 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that in this 
case, the documentation doesnt support that the enrollee requires additional skilled nursing services or skilled 
rehab services to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollees condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (E0676) provided on January 18, 
2023. 
 
You asked the Plan to pre-approve E0676. You say that these compression stockings are medically necessary. 
The Plan denied your request. The Plan says the requested compression stockings are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say beginning on January 1, 2024, coverage is available 
for compression garments for lymphedema treatment.  
 
We looked at the file and Medicare rules. The documentation shows that the compression stockings are not 
being requested for the treatment of lymphedema. Though the items may be appropriate, Medicare coverage is 
limited to compression garments for lymphedema treatment. Therefore, we decided that the Plan does not have 
to pre-approve compression stockings (E0676) provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine, and the administration provided on 
October 02, 2023. 
 
You asked the Plan to pay for the influenza vaccine, and the administration. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the influenza vaccine, and the administration provided on October 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy (45380) and the 
esophagogastroduodenoscopy (43239, 43248) provided on July 13, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy (45380) and the esophagogastroduodenoscopy 
(43239, 43248). You say that you thought the services would be covered in full. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 
$405.00 copayment for outpatient surgery. 
 
You have been asked to pay a $405.00 copayment for the colonoscopy (45380) and the 
esophagogastroduodenoscopy (43239, 43248). This item/service falls within the outpatient surgery 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. Therefore, we 
decided that the Plan does not have to waive the copayment for the colonoscopy (45380) and the 
esophagogastroduodenoscopy (43239, 43248) provided on July 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide SNF services 
 
You asked the Plan to provide SNF services. You say that the enrollee has received 100 days of SNF care, but 
still requires rehabilitation services. The Plan denied your request. The Plan says they have already covered 
100 days of SNF care during this benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 4, 2023, 
to January 21, 2024. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to provide SNF 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 enrollee has a severe lower extremity swollen 
impairing ambulation. You also say that the enrollee has chronic shortness of breath when walking and has 
been treated with diuretics for the lower extremity swelling so the ambulation improves. The Plan denied your 
request. The Plan says based on the available information, admission to IRF is not reasonable and necessary, as 
the enrollee's condition does not meet the Medicare rules.  
 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. The enrollee 
was admitted for congestive heart failure. 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87086 and 81007) 
rendered on July 26, 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 Current Procedural Terminology (CPT) code 87086-59 and 81007 remain not supported. 
 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 81007: 
 
Urinalysis; bacteriuria screen, except by culture or dipstick 
 
CPT 87086: 
 
Culture, bacterial; quantitative colony count, urine 
 
In this case, we have confirmed that code 81007 is a column two code to column one code 81003 with a 
modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
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 for CPT 87086. Our reviewer says that the services at issue in this case 
were not supported. Our reviewer found that there is no evidence that a urinalysis or urine culture were 
performed. 
 
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 laboratory services (procedure codes 87086 and 81007) rendered on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on September 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says your benefit for the periodic oral evaluation has already been exhausted. 
Additionally, your maximum allowance of $1000 has been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the periodic oral evaluation was exhausted on dates of service January 9, 2023, and 
January 18, 2023. Additionally, your maximum allowance of $1000 has been exhausted. Therefore, we decided 
that the Plan does not have to pay for a periodic oral evaluation (D0120) and periodontal maintenance (D4910) 
provided on September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/ investigational therapy. It is the subject of ongoing 
clinical trials. Therefore, the reviewer found that the requested genicular nerve block is not 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 the nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
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 the enrollee needs SNF services. The Plan denied 
your request. The Plan says that the enrollee does not meet the requirements for an SNF admission. 
 
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 clinical documentation provided shows that the enrollee's past level of 
function was independent with mobility and self-care tasks. Current therapy notes show that all short-term 
skilled therapy goals have been met and the enrollee is progressing with long-term goals. The documentation 
provided does not specify any daily skilled nursing needs therefore the medical necessity of daily skilled 
services is not supported. As a practical matter, clinical documentation does not support the medical necessity 
of daily skilled services on an inpatient basis in a SNF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has been experiencing 
constant pain. You say that the enrollee is exacerbated by bending and walking, which both symptoms of 
vertebrogenic pain. The Plan denied your request. The Plan says the intracept procedure 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 the intracept procedure. Our reviewer 
says that the intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease, and 
the cause of pain is not clear.  
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and bitewings (D0274) provided on August 18, 2023, to August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this dental work should be paid. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 14, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging (D0220), 
and bitewings (D0274) provided on August 18, 2023, to August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 3 sensor. You say that the enrollee reports their 
hypoglycemic events started to happen after bariatric surgery and were mostly related to high carbohydrate 
content meals. You also say that lately, there has not been relation to meals, and it can even occur at night. The 
Plan denied your request. The Plan says they did not get any information showing the enrollee meets the 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 3 sensor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an SI joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the requested injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements 
for the injections to be approved. 
 
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 an SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have signs supporting the diagnosis of sacroiliitis. Therefore, 
the request is deemed not 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 an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an SI joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 24, 2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the services were emergent and 
should be paid. The Plan denied your request. The Plan says the services provided were included in the 
inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the documentation provided does not contain medical records in regard to inpatient 
admission. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
August 24, 2023.