Persius/hicric huggingface dataset:
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 LTACH remains the only choice for a 
discharge plan for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate in-patient acute care and is currently unstable for transfer to an 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 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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Monovisc (J7327). 
 
You asked the Plan to pre-approve treatment with Monovisc. You say that Monovisc is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that rules for coverage of Monovisc have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 treatment with Monovisc. Our reviewer 
says that Monovisc is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of severe unilateral primary osteoarthritis of the right knee and has had no relief with 
corticosteroid injections in the past. The enrollee was also treated with platelet-rich plasma (PRP) injections. It 
is documented that the enrollee was using Tylenol for pain control, as well as topical creams and deep tissue 
massage. A previous Monovisc injection on December 8, 2022, provided significant relief of symptoms for 
about 3 months. Monovisc is indicated for the treatment of the pain of osteoarthritis of the knee in patients who 
have failed to respond adequately to conservative nonpharmacologic therapy and to simple analgesics, as the 
enrollee has. The documentation supports that Monovisc is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with Monovisc have been met. Therefore, we decided that the Plan 
has to pre-approve treatment with Monovisc (J7327).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of long-term acute 
care for ongoing medical management for vent and trach weaning with the goal of decannulation. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently 
unstable for transfer to an 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 the enrollee appears to still be somewhat unstable 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. Our 
reviewer found that a transfer to the LTACH is not medically necessary as the enrollee is not yet stable for 
transfer and as it would not be clinically advantageous. Our physician reviewer also found that 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
restrictive lung disease. Provided records document that the home ventilator is being requested for use in an 
intelligent volume assured pressure support or average volume-assured pressure support (IVAPS or AVAPS) 
mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support AVAPS and a back-up rate. Provided records do not document trial 
and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that sclerotherapy is medically necessary. The Plan 
denied your request. The Plan says the member has saphenous reflux, therefore the criteria is not met for 
coverage of sclerotherapy. 
 
The Plan follows Medicare rules. Medicare rules say that sclerotherapy is covered when the criteria listed in the 
Medicare rules section of this decision 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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not considered medically necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has varicose veins including untreated reflux in the proximal 
saphenous. The record provided does not provide documentation of the failure of conservative treatment or the 
presence of complicating factors. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
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 acute rehabilitation because is medically necessary 
for the enrollee to regain his strength and return independent. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for acute rehabilitation. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93799 billed for date of service September 
7, 2021. 
 
You asked the Plan to pay for procedure code(s) 93799. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 93799 has a Professional/Technical indicator of 1. This means that CPT code 93799 has 
both a professional and technical component. In this case, CPT code 93799 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93799 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 93799 billed for date of service September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 9, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99283 
for January 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre- and post-operative services are included in the 
global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99283 was related to and billed on the same day as 
minor surgical procedure 10061 billed on November 14, 2022. Payment for code 99283 is included in the 
global surgical payment for 10061. Therefore, we decided that the Plan does not have to pay for the emergency 
room (ER) services billed with code 99283 for January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 
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 RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the LCD criteria requires 2 separate sets of 
diagnostic MBBs be performed, each of which produce 80% or greater pain relief. Only one set has been 
performed and therefore, at this time, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 25, 
2022, to November 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that given the grave condition of the 
enrollee, an inpatient admission was medically necessary. The Plan denied your request. The Plan says an 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was stable hemodynamically, did not require invasive or complex 
treatment. There was no expectation that the enrollee would have required hospital care that would have likely 
crossed two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 25, 2022, to November 26, 
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 the enrollee would benefit with acute rehabilitation 
and would have faster improvement. The Plan denied your request. The Plan says the enrollee's records do not 
show you need an intensive team (rehab doctor and nurse, social worker, and therapists) for care. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan of 
the head or brain provided by an out-of-network provider on February 6, 2023, and February 10, 2023, and the 
critical care services provided by an out-of-network provider from March 4, 2023, to March 10, 2023. 
 
You asked the Plan to waive the cost sharing for the computed tomography (CT) scans, and the critical care 
services. You say that you think that these services should be processed as in-network. 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 40% 
coinsurance for out-of-network inpatient care, as well as out-of-network provider and professional services 
provided in an inpatient hospital. 
 
You have been asked to pay a $616.66 coinsurance for the computed tomography (CT) scans, and the critical 
care services ($1541.68 allowed amount x .40 = $616.66 rounded down). These items/services fall within the 
inpatient hospital 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 cost sharing for the 
computed tomography (CT) scan of the head or brain provided by an out-of-network provider on February 6, 
2023, and February 10, 2023, and the critical care services provided by an out-of-network provider from March 
4, 2023, to March 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 16, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99285 is bundled into payment for code 99222. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99285 
is a column II code to column I code 99222 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99285 billed for date of service February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic - porcelain fused to predominantly base metal tooth 
#s 7, 12 and 14 (D6241), and retainer crown - porcelain fused to predominantly base metal tooth #s 9, 11 and 
13 (D6751) provided on February 23, 2023. 
 
You asked the Plan to pay for the pontic - porcelain and retainer crown - porcelain. You say that you cannot 
wear dentures and these services are a medical necessity.  The Plan denied your request. The Plan says the 
information sent by your dentist does not tell us why a denture cannot be used to replace your missing teeth. 
The request for a bridge is denied.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  The Plan covers pontic - porcelain and retainer crown - porcelain when the services are medically necessary 
and reasonable.  
 
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 pay for the pontic - porcelain and retainer crown - 
porcelain. Our reviewer says that the pontic - porcelain and retainer crown - porcelain are not medically 
necessary. Our physician reviewer found the provided records in this case consist of dental x-rays with no 
written documentation from the dental provider as to the necessity of the specific services requested - white 
glass with metal cap for bridge tooth #'s 9, 11 and 13 (D6751) and false tooth for bridge tooth #'s 7, 12 and 14 
(D6241). The documentation provided does not meet the criteria for coverage for a fixed bridge replacing 
missing teeth #'s 10, 12 and 14. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic - porcelain and retainer crown - porcelain have not been met. 
Therefore, we decided that the Plan does not have to pay for a pontic - porcelain fused to predominantly base 
metal tooth #s 7, 12 and 14 (D6241), and retainer crown - porcelain fused to predominantly base metal tooth 
#s 9, 11 and 13 (D6751) provided on February 23, 2023.