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

 
We decided that the Plan has to pay for procedure code 31622 provided on April 5, 2023. 
 
You asked the Plan to pay for procedure code 31622. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure code 31622 based on Medicare criteria. The file shows that codes 31622 and 31526 are 
separate procedures and can be paid for separately. Per Medicare guidelines, when billing for multiple surgeries 
by the same physician on the same day, report the additional surgical procedure performed by the surgeon on 
the same day with modifier -51. The Plan has provided no evidence to support that these two codes cannot be 
separately paid as billed. Therefore, we decided that the Plan has to pay for procedure code 31622 provided on 
April 5, 2023.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says that the enrollee does not meet the requirements for an LTACH 
admission. 
 
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 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 is receiving appropriate care at the present acute care hospital. There 
is no evidence that an LTACH would provide a therapeutic advantage over the acute care hospital. The plan is 
not requiring the enrollee to be transferred to a lower level of care at this time. The requested services can be obtained at the acute care hospital where the enrollee is receiving care. Additionally, a transfer to an LTACH 
may not be medically safe at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a HFCWOD.  
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for a HFCWOD. Our physician reviewer found the enrollee does not have a 
diagnosis of bronchiectasis but does have asthma and post nasal drip with associated cough comprising of thin 
secretions documented. The enrollee does not meet criteria for high frequency chest wall oscillation devices 
(HFCWODs) per data and documentation provided. Hence, no high frequency chest wall oscillation devices 
(HFCWODs) indicated at this time. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services provided on April 27, 2023. 
 You asked the Plan to pay for the hospital discharge services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge services provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wound care services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the wound care services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the services are available with plan providers. 
 
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. 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 
the wound care services to be provided by an out-of-network (OON) provider.
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 meets the criteria for an 
LTACH admission. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, but they could review alternate settings if requested such as a skilled nursing facility (SNF), 
outpatient setting or home health 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 the services the enrollee requires are currently available at the acute care hospital 
where the enrollee is currently receiving care. Ongoing care at the acute hospital has not been denied. The record does not demonstrate a therapeutic advantage to the LTACH over the acute care hospital. The requested 
services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and are able to be furnished safely and effectively only on an inpatient basis. However, these services are able 
to be obtained at the acute care hospital where the enrollee is 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections for pain management. 
 
You asked the Plan to pre-approve epidural steroid injections for pain management. You say that it is medically 
necessary. The Plan denied your request. The Plan says that it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the ESI will be considered medically reasonable and 
necessary if the three requirements are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injections for pain 
management. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee meets all of the LCD criteria and the request is medically reasonable and necessary. Performance of a 
cervical Epidural steroid injection at C7-T1 is standard 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 epidural steroid injections for pain management have been met. Therefore, we 
decided that the Plan has to pre-approve epidural steroid injections for pain management.  
 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 LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says that the enrollee does not meet the requirements for an LTACH 
admission. 
 
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 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 appears to be improving with the current treatment but is still not yet 
stable for transfer and should only require short-term additional acute care hospital services that can safely be 
provided at the current treatment facility until more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantages. 
Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office care to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve office care. You say that you want to see this provider to treat your 
conditions. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you 
can be treated within the Plan network. 
 
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. 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 
office care to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs or non-routine services for durable medical 
equipment (DME) other than oxygen equipment (K0739 x25) and additional items and accessories (codes 
E2363 x2, E2366, K0108 x9, K0017 x2, K0018, K0019, E2231, E0978, E2374, E2394 x2, E2386, E2392, 
E2396, E2392, E2396, E2375, E2370 x2).  
You asked the Plan to pre-approve repairs or non-routine services for DME and additional items and 
accessories. The Plan denied your request. The Plan says although service work order has good justification for 
repairs, there is concern for abuse/neglect of DME provided by the health plan. The Plan also says this appears 
to be excessive repairs in a relative short period of time. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repairs or non-routine services for DME and additional items and accessories have not been met. 
Specifically, the record shows that the cumulative cost of repairs that have already been made to the current 
wheelchair is $16,091.46. The sum of the repairs which have already been made to the wheelchair plus the sum 
of the repairs being requested in this appeal total more than the cost for an identical replacement wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve repairs or non-routine services for durable 
medical equipment (DME) other than oxygen equipment (K0739 x25) and additional items and accessories 
(codes E2363 x2, E2366, K0108 x9, K0017 x2, K0018, K0019, E2231, E0978, E2374, E2394 x2, E2386, 
E2392, E2396, E2392, E2396, E2375, E2370 x2).
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 for 
the enrollee's complex medical needs.  The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current setting.  
 
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 enrollee appears to still be unstable and guarded and requires additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
The enrollee does not require services at the LTACH that are not already available at the current 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
June 9, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of both breasts. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the requested imaging.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the enrollee has no documented family history 
of breast cancer and no known other risk factors. The enrollee does not meet the criteria of estimated lifetime 
risk and would be considered low risk. Therefore, the MRI is 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of both breasts.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 8, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute. 
 
You asked the Plan to pre-approve skin substitute. You say that it is medically necessary. The Plan denied your 
request. The Plan says it 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 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 skin substitute is a pressure ulcer and therefore the skin substitute is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 25, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 4, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test detects pathogens, abnormalities, and 
diseases accurately. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The file shows that the panel testing was billed using codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 
87532, 87563, 87591, 87661, 87481, 87651, 87653, and G0452. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service August 4, 2023.