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 the enrollee's medical and functional needs will be 
best met and managed in an IRF level of care. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements. Services needed may be provided safely in 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4450 and A6446 billed for date of service 
November 18, 2022. 
 
You asked the Plan to pay for procedure codes A4450 and A6446. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 44 units of CPT code A4450 are not supported in the case record. The case record only supports 1 
unit of CPT code A4450. We also find that 123 units of CPT code A6446 are not supported in the case record. 
The case record only supports 30 units of CPT code A6446. Based on this information, we decided that 
Medicare rules for coverage of procedure codes A4450 and A6446 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4450 and A6446 billed for date of service November 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 17, 2023, billed with 
evaluation and management (EM) code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the benefit for this service in included in the 
payment/allowance for another service/procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that Modifier 25 is used to facilitate billing of 
evaluation and management services on the day of a procedure for which separate payment may be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Modifier 25 was not billed on the claim to 
represent these services as separate/distinct. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on April 17, 2023, billed with evaluation and management (EM) code 99232.
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 you would like an extension past your 100-day 
benefit. The Plan denied your request. The Plan says your 100-day SNF benefit will be exhausted by 
September 11, 2023. 
 
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 you will have received 100 days of SNF care during the benefit period from June 3, 2023, 
through September 11, 2023. The Plan will have covered 100 days of SNF care. 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from February 25, 2023, to 
February 26, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim is separate from the facility claim. 
The Plan denied your request. The Plan says you billed an incorrect Place of Service code on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from February 25, 2023, to February 26, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a diagnostic or therapeutic injection (62323) 
 
You asked the Plan to pre-approve a diagnostic or therapeutic injection. The Plan denied your request. The Plan 
says that a lumbar epidural steroid injection (ESI) is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale for at least three months. 
 
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 diagnostic or therapeutic injection. 
Our reviewer says that the requested procedure is medically reasonable and necessary. Our physician reviewer 
found the enrollee had greater than 3 months of greater than 50% pain relief. 
 
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 diagnostic or therapeutic injection have been met. Therefore, we decided that 
the Plan has to pre-approve a diagnostic or therapeutic injection (62323)  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 to be seen by a 
rehabilitation doctor at least three times a week for evaluation of functional and medical goals and progress. 
Services needed may be provided safely in 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed. 
 You asked the Plan to pre-approve a hospital bed. You say that you are appealing for the denial a larger 
hospital bed. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
requested hospital bed. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file, and Medicare rules. The records show that the enrollee weighs 278 pounds therefore the 
weight criteria has not been met. The records also show that the enrollee was already approved for a semi-
electric hospital bed on June 20, 2023. Based on this information, we decided that Medicare rules for coverage 
of a hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy 
duty, extra wide hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for the 
enrollee to maintain their independence. You also say the enrollee is not safe to return home and requires the 
intensity of the program to rehabilitate and return home. The Plan denied your request. The Plan says 
admission to an IRF is not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
  You asked the Plan to pre-approve additional mileage. You say that you have no transportation to this 
appointment, and it exceeds the Plan's mileage limitations. You also say that this is a crucial and important 
appointment, and you really need approval for the extra mileage so you can have transportation arranged. The 
Plan denied your request. The Plan says the requested location is approximately 78.6 miles from your home, 
which exceeds the mileage for the benefit. The Plan also says there are multiple Neurological Surgeon's within 
the 60-mile radius of your home that you can see. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trip is no more than 60 miles one way.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a emergency room visit provided on May 
24, 2023. 
 
You asked the Plan to waive the copayment for a emergency room visit. You say that you disagree with the 
copayment. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for a emergency room visit. This item/service falls within the 
emergency care 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 a emergency room visit 
provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the destruction of premalignant lesions 
provided on January 19, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and the destruction of premalignant lesions. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says these services 
were not authorized. 
 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 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 pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and the destruction of premalignant 
lesions provided on January 19, 2023, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 2, 2022 to 
August 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 2, 2022 to 
August 31, 2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding the 
submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a T11 kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the enrollee has completed conservative care 
over the past year. You say that the imaging provided shows the fracture has not healed. You also say that it 
continues to cause pain and discomfort for the enrollee. The Plan denied your request. The Plan says that this 
service is 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 pre-approve the kyphoplasty. Our reviewer says that 
the request for a T11 kyphoplasty is medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has 35% vertebral height loss of T11 with mild retropulsion of the 
vertebral body. The reviewer found that the present retropulsion is described as mild and a recent study 
revealed minimal risk of cement entering the canal when the kyphoplasty is carefully done. The reviewer also 
found that retropulsion is listed as a relative contraindication and not an absolute one in the guidelines. 
Therefore, the reviewer found that the requested kyphoplasty 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 the kyphoplasty have been met. Therefore, we decided that the Plan has to pre-
approve a T11 kyphoplasty.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 30, 2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says services requested do not meet the requirements for 
approval. Services needed may be provided safely in a lower level of care.  
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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.