Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that this treatment is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that there is not enough evidence to show that the enrollee's type 
of cancer responds better to this type of treatment than to radiation therapy. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found It seems as though IGRT is simply being used as routine practice, as there does not seem to be 
any exceptional circumstances with this patient necessitating the need for IGRT and the records do not justify 
the need for IGRT.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0008). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested wheelchair. 
 
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.  
 
 
 The file shows that the enrollee does not have a mobility deficit that impairs your participation in MRADLs or 
the enrollee's condition can be improved by a walker, cane or manual wheelchair. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve an ultralightweight wheelchair (K0008).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the diagnostic colonoscopy provided on 
May 03, 2023. 
 
You asked the Plan to reduce the copayment for the diagnostic colonoscopy. You say that you are on a fixed 
income and cannot afford this high of a 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 $290 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $290 copayment for the diagnostic colonoscopy. This item/service falls within 
the in-network 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 reduce the copayment for 
the diagnostic colonoscopy provided on May 03, 2023.
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 it is in your best clinical judgment that 
the enrollee's medical condition does qualify them to be admitted to an LTACH for continued acute care, which 
cannot safely be provided at a lesser level of care. The Plan denied your request. The Plan says the request for 
admission to an LTACH is not medically necessary.  
 
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 current acute care hospital can provide for all the enrollee's present inpatient 
care needs. The enrollee is receiving an appropriate level of care in the present setting, and the Plan has stated 
that continued care in the short-term acute hospital will be covered as is medically indicated. Continued care in 
the present short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care 
such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
(myocardial perfusion imaging). 
 
You asked the Plan to pre-approve the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show an inability to exercise or an uninterpretable electrocardiogram. 
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not demonstrate any contraindication for a regular treadmill exercise test. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve single photon emission computed tomography (SPECT) (myocardial perfusion imaging).
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 enrollee meets an IRF level of care. You would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee 
does not meet all the requirements for an IRF admission.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0299, Q5001) 
provided on December 8, 2022, to December 22, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 8, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0152, G0299, Q5001) provided on December 8, 2022, to December 22, 2022.
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 you are appealing this denial. The Plan denied your 
request. The Plan says  based on the available information, admission to the IRF is not reasonable and 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you 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 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON PCD. You say that the enrollee has had a successful trial of this 
OON PCD. It is felt that it should be covered by the Plan.  The Plan denied your request. The Plan says there is 
a network provider able to furnish the type of PCD requested. Approval has been granted to receive the device 
from the network provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. There is no evidence presented to support 
that only this particular brand of PCD can meet the enrollee's needs. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested provider. 
 
You asked the Plan to pre-approve hearing aids to be provided by the requested provider. You say that the 
requested provider is closer to you; about 15 miles and the locations that the Plan offer are all out of state, 
which would require you to drive about an hour or more when you go out of state and then you are required to 
pay sales tax, which is not required in your state. The Plan denied your request. The Plan says hearing aids 
purchased outside of the Plan's Hearings nationwide network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans nationwide network. 
 
We looked at the file and the Plan's rules. The file shows that hearing aids purchased outside of the Plans  
nationwide network are not covered. Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids 
to be provided by the requested provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint (64625). 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan 
denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is bundled/excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service February 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 3, 2022, 
through October 26, 2022.  
 You asked the Plan to pay for the home health services. You say that submission of the documentation supports 
that payment should be made.  The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 3, 2022. There is no evidence that an NOA was submitted to the 
Plan within the 30 days after the start of this period. As more than 30 days passed between the timely filing 
date and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from October 3, 2022, through October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on July 21, 2022, 
to July 22, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the service is not supported without required documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the medical records 
submitted do not include documentation of a subsequent hospital care evaluation and management note for the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of subsequent 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care (99233) provided on July 21, 2022, to July 22, 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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested 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 that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. 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. 
 
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 pay for home health services (G0151, Q5001) provided on June 30, 
2022, to July 21, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 1, 2022. The NOA was not received by the Plan until August 16, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
Q5001) provided on June 30, 2022, to July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care treatment (Nushield) (Q4160), application 
of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple 
digits (15275) and application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet, and/or multiple digits, total wound surface area up to 100 square (sq) centimeter (cm); each 
additional 25 sq cm wound surface area, or part thereof (15276). 
 
You asked the Plan to pre-approve wound care treatment and skin substitute. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says documentation does not 
show why the enrollee's condition supersedes criteria. 
 
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 wound care treatment and skin 
substitute. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is being treated for a diabetic foot ulcer. It is 
documented in a progress note dated June 8, 2023, that wound #4 was acquired on September 1, 2022. The 
progress note documents that the wound has been in treatment for 26 weeks. The wound measured 2.2cm long, 
2.2cm wide, and 0.1cm deep. The wound was debrided, and Nushield was applied to the wound bed. The 
documentation does not support that continued use of skin substitute is medically reasonable and necessary for 
this enrollee after 26 weeks of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care treatment and skin substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve wound care treatment (Nushield) (Q4160), application of 
skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple 
digits (15275) and application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet, and/or multiple digits, total wound surface area up to 100 square (sq) centimeter (cm); each 
additional 25 sq cm wound surface area, or part thereof (15276).