Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service March 2, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 16 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service March 2, 2023.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee could receive treatment at a lower level of 
care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical record does not show prior medial branch blocks nor is there 
documentation as to why radiofrequency ablation cannot be performed. 
 The Plan follows Medicare rules. Medicare rules say that in order for thermal radiofrequency destruction of 
lumbar paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must 
have had at least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
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 facet joint injection. Our reviewer says 
that the enrollee does not meet coverage criteria. Our physician reviewer found you have not had 2 sets of 
medial branch blocks. There is no documentation as to why you are not a candidate for medial branch blocks 
and then radio-frequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to move to the next 
level of care as they have completed their current treatment. The Plan denied your request. The Plan says an 
LTACH admission 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 that the enrollee does not require services at a LTACH that are not available at the 
acute care hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on 
February 21, 2023.  
 
You asked the Plan to pay for the ambulance without transport services. You say that the ambulance staff 
stabilized your condition, and you felt the transport was optional. The Plan denied your request. The Plan says 
since there was no transport, ambulance charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on February 21, 2023.
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 an acute inpatient rehabilitation stay is the only level 
of care that can ensure the enrollee's maximal gains following thier discharge from their current inpatient 
setting. The Plan denied your request. The Plan says an IRF admission 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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance without transport services received on April 
19, 2023. 
 
You asked the Plan to pay for the ambulance without transport services. You say that you were told that you 
would not be charged since you did not take the ambulance. The Plan denied your request. The Plan says since 
you were not transported by this ambulance, the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance without transport services received 
on April 19, 2023.
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 say that you disagree with the denial for the 
admission to an IRF. The Plan denied your request. The Plan says these services the enrollee needs can be 
provided safely in other settings.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement; however, the 
documentation doesnt support that they would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the member would require skilled rehabilitation in an IRF.  The enrollee 
can receive further services at a lower 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: 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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has no daily skilled nurse or therapy needs. 
 
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 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: 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 member wants to go to rehab for therapy. The Plan 
denied your request. The Plan says this 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 On review of the available records, the enrollee with debility from acute UTI and 
sepsis as described above does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable as described above and does not need PMR physicians supervision 3 times a 
week in an IRF. 
There is no active medical complexity. 
 No acute rehab nursing needs documented. 
At the current functional level (Sup/CGA) the enrollee needs PT, OT and does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. 
Document does not support necessity for admission to an IRF. The complexity of the enrollees medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
IRF admission is not necessary and is not reasonable. 
The enrollees rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF or 
in-home with services and family support.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reduction mammaplasty (19318). 
 
You asked the Plan to pre-approve reduction mammaplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because the records show this surgery is to 
reduce excessive skin after weight loss. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that reduction mammaplasty can be covered under specific 
conditions. 
 
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 reduction mammaplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has had weight loss and has excessive loose 
skin. The record provided does not document the presence of macromastia or the existence of an enumerated 
condition for which coverage is available under the rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reduction mammaplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve reduction mammaplasty (19318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital bed (E0301) and mattress (E0277). 
 
You asked the Plan to pre-approve the hospital bed and mattress. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the requested hospital bed is not available for home 
use. You were provided an alternative bed and mattress option. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Plans may 
specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may 
limit the durable medical equipment (DME) to only those preferred brands and manufacturers, as long as they ensure that enrollees have access to all medically necessary. 
 
Records show that the hospital bed and mattress is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve the hospital bed (E0301) and mattress (E0277).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 19, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the services should be paid for. The Plan 
denied your request. The Plan says these services were not urgent or emergent, and not referred by a 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 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 physical therapy services provided on July 19, 
2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tyrvaya. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this drug. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve use of Tyrvaya.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 6, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 6, 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 the services are medically necessary. The 
Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require 
transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are currently undergoing treatment at an acute care hospital (ACH). There is 
no evidence that you require services that are not currently available. You can remain at the current ACH until 
such time no acute services are required. You can then be transferred or discharged to a lower level of care for 
any ongoing long term care needs. 
 
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.