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 the enrollee is currently stable and meets 
criteria for LTACH level of care. The Plan denied your request. The Plan says the enrollee does not meet all 
the requirements. The Plan says that the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the injection. You say that you are requesting reconsideration as you are still 
having a lot of back pain. The Plan denied your request. The Plan says the requested service is not 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 injection. Our reviewer says that the 
service is not medically reasonable and necessary. Our physician reviewer found the LCD requires 50% pain 
relief for three months after an ESI. This was not achieved. A repeat ESI may be performed at a different level 
or approach after two weeks if there is insufficient pain relief, but that was not done in this case. There is no 
documentation that the provider plans on using a different approach, level and/or medication.    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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows facet degenerative joint disease and stenosis. The 
cause of pain is not clear. 
 
   
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 20, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on March 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this should have been included in the 
cost sharing for the surgery. 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 
copayment for in-network outpatient diagnostic x-rays provided at a free-standing radiology facility. 
 
You have been asked to pay a $40 copayment for the x-ray. This item/service falls within the in-network 
outpatient diagnostic x-rays provided at a free-standing radiology facility 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. The x-ray (CPT code 73630LT) is not 
included in the global period for the surgery, and the copayment was correctly applied. However, since the 
allowed amount is less than the standard copayment, you only owe $27.90. Therefore, we decided that the Plan 
does not have to waive the copayment for the x-ray provided on April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided on January 24, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that the use of a surgical assistant was 
medically necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided on 
January 24, 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 the services are medically necessary to provide you 
with the level of care needed. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: 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 unable to get care at home and need to 
improve your condition. The Plan denied your request. The Plan says your records do not show that you require 
the intensity of three hours of daily therapy provided in the IRF setting. 
 
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 your 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
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 enrollee is medically stable. The records do not show that the enrollee requires 
intensive therapy services. The enrollee's needs do not support the necessity for an IRF stay. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 06, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
provided on April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs or nonroutine services for durable medical 
equipment (DME) (K0739 x7), wheelchair components or accessories (K0108 x3), retractable or removable 
mounting hardware for joystick (E1028), adjustable angle footplate (K0040), lower extension tube replacement 
for footrest (K0043 x2), and skin protection and positioning wheelchair seat cushion (E2624). 
 
You asked the Plan to pre-approve the wheelchair repairs and items. The Plan denied your request. The Plan 
says the requested repairs do not meet medical necessity criteria.  
 
The Plan follows Medicare rules. Medicare rules say that during the reasonable useful lifetime, Medicare does 
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment 
owned by the beneficiary. 
 
 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 wheelchair repairs and items. Our 
reviewer says that this request is not medically necessary. Our physician reviewer found that the Plan has 
chosen to offer replacement rather than repair of the enrollees current wheelchair. Per plan records, the current 
wheelchair is more than 5 years old. Our reviewer also found that it is reasonable to replace the wheelchair as 
opposed to repair it. 
 
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 wheelchair repairs and items have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repairs or nonroutine services for durable medical equipment (DME) 
(K0739 x7), wheelchair components or accessories (K0108 x3), retractable or removable mounting hardware 
for joystick (E1028), adjustable angle footplate (K0040), lower extension tube replacement for footrest (K0043 
x2), and skin protection and positioning wheelchair seat cushion (E2624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile imaging services provided on January 10, 2023. 
 
You asked the Plan to pay for mobile imaging services. You say that these services were required for 
immediate evaluation of the enrollee. The Plan denied your request. The Plan says this claim was not billed 
with the appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit provides service for an entity for 
which another Place of Service (POS) code already exists, the provider should use the POS code for that entity.  
 
We looked at the file and Medicare rules. These services were provided for a skilled nursing facility. Therefore, 
the POS code 11  indicating an office setting  is not appropriate for this claim. Based on this information, we 
decided that Medicare rules for coverage of mobile imaging services have not been met. Therefore, we decided 
that the Plan does not have to pay for mobile imaging services provided on January 10, 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 the services are medically necessary for you to 
receive the care needed. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to an IRF. 
 
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 you are medically stable. You do not require intensive therapy services. Your care 
needs can be provided in an alternate and low intensity setting such as a skilled nursing facility or continued 
services 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 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive physical and occupational therapy services. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an IRF. 
 
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 enrollee is medically stable. There are no acute rehab nursing needs identified or 
documented. The enrollees rehab needs can be addressed in an alternative setting such as in-home with 
services. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service March 20, 2023. 
 
You asked the Plan to pay for the billed services. You say that the date of service is correct. The Plan denied 
your request. The Plan says that the date of service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. The records provided show that the specimen was collected on December 
28, 2022. As the specimen was stored for more than 30 days, the date of service was accurately billed as the 
date the specimen was obtained from storage. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for the lab testing 
billed for date of service March 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Micro-Invasive Glaucoma Surgery (MIGS) (66991). 
 
You asked the Plan to pre-approve MIGS. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary s the enrollee does not have mild or moderate glaucoma. 
 
The Plan follows Medicare rules. Medicare rules say that up to two iStent aqueous drainage devices, or one 
Hydrus device per eye will be considered medically reasonable and necessary for the treatment of adults with 
mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an 
ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery. 
 
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 MIGS. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found the enrollee is noted to have severe 
stage glaucoma, and therefore does not meet the criteria. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MIGS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Micro-Invasive Glaucoma Surgery (MIGS) (66991).
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 a lower level of care is not safe, sufficient, or 
equipped to address the enrollee's needs related to comorbidities and allow the opportunity to gain a higher 
level of functioning to improve quality of life. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare criteria. The Plan says that the 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.