Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
March 1, 2023, through March 31, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that this enrollee was admitted for acute inpatient psychiatric hospitalization on September 22, 2022 with 
Schizoaffective Disorder Type. Based upon the review of the records provided, it was not expected that this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations, and was without aggressive behaviors while 
not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or abnormal 
behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. This 
enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was 
not a danger to himself or others and did not have any delusions, or auditory and visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or were for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a 
physician. Based upon the review of the records provided, this enrollee does not meet criteria for coverage of 
the acute inpatient mental health treatment provided beyond the date in question of March 1, 2023 forward and 
could have been treated in a lesser restrictive 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from March 1, 2023, through March 31, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 29826 billed for date of service January 9, 
2023. 
 
You asked the Plan to pay for procedure code 29826. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 29826 is bundled into payment for code 23412. 
 
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 29826 
is a column II code to column I code 23412. 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 29826 billed for date of service January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary due to 
your condition. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D2954). 
 
You asked the Plan to pay for the dental service (D2954). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service (D2954) is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D2954).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve Botox. You say that the office only uses Botox. The Plan denied your 
request. The Plan says the enrollee has not tried one of the preferred drugs.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our physician reviewer found 
that the enrollee has a diagnosis of spasmodic torticollis, with cervical dystonia. The Plan requires a trial of 
Dysport or Xeomin before they will approve the requested drug. The case file does not contain documentation 
of trial and failure of Dysport or Xeomin. The clinical documentation does not support that Dysport or Xeomin 
would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
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 not medically necessary. 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules 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 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: Favorable

 
We decided that the Plan has to pay for procedure code 99291 for date of service April 15, 2023, and April 16, 
2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the medical records do not support that a critical care visit of 30-
74 minutes was performed. 
 
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, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
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 procedure code 99291. Our reviewer says 
that the documentation supports the code billed. Our reviewer found the enrollee has a history of diabetes, 
hypertension, prostate cancer. The enrollee presented with worsening upper extremity weakness, developed 
acute respiratory failure requiring mechanical ventilation, and acute kidney injury. The documentation does 
support a critical care visit of 30-74 minutes was performed on both April 15, 2023, and April 16, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99291 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99291 for date of service April 15, 2023, and April 16, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary for the 
enrollee to further their progress and return to their activities of daily living. The Plan denied your request. The 
Plan says the enrollee's condition does not meet Medicare guidelines for services in 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 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's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose injection (Injectafer) (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that the enrollee's most recent iron panel showed low 
iron saturation and low folate levels. You say the enrollee complains of fatigue and would benefit from iron 
infusion. The Plan denied your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
criteria for coverage of Injectafer have not been met. Our physician reviewer found that the Plan requires a trial 
of Venofer, Infed, Ferrlecit or Feraheme before they will approve Injectafer. The record does not contain 
documentation of trial and failure of the Plans required drug(s). The clinical documentation does not support 
that Venofer, Infed, Ferrlecit or Feraheme would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ferric carboxymaltose injection (Injectafer) (J1439).
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. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for continuation of care at a SNF facility. 
 
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 and/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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nonsterile gloves (A4927) purchased on May 24, 2023.. 
 
You asked the Plan to pay for the nonsterile gloves. You say that the item should be covered. The Plan denied 
your request. The Plan says Medicare does not cover hygienic equipment since it is not primarily medical 
in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the nonsterile gloves (A4927) purchased on May 24, 2023..
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
9, 2022, to September 29, 2022. 
 
You asked the Plan to pay for SNF care. You say that you expect to be paid. The Plan denied your request. The 
Plan says the Plan has changed the patient drive payment model (PDPM) code from JAXF1 to ZZZZZ. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SNF care have been met. No 
supporting medical records were submitted for review. The Plan requested supporting documentation, but none 
was submitted. Without this information, we cannot determine whether the PDPM code billed on this claim is 
supported. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided from September 9, 2022, to September 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 11, 
2023, by an OON provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 subsequent nursing facility care provided on 
May 11, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan.  Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the air ambulance transport services provided on March 28, 
2023. 
 
You asked the Plan to pay for the air ambulance transport services. You say that the services were a medical 
emergency and air transport was medically necessary. The Plan denied your request. The Plan says the records 
do not support the criteria for air ambulance transport has been met. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport services. Our 
reviewer says that the air ambulance transport was not medically necessary. Our physician reviewer found the 
enrollee required transportation by ambulance. The documentation does not sufficiently support that the time 
needed to transport the enrollee by ground, or that the instability of transportation by ground, posed a threat to 
the enrollee's survival or seriously endangered their health. The documentation supports that the transferring 
hospital did not have adequate facilities to provide the medical services needed however, transportation by air 
ambulance was not medically reasonable and necessary in this case. 
 
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 air ambulance transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the air ambulance transport services provided on March 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the vedolizumab (J3380) provided on 
April 27, 2023. 
 
You asked the Plan to waive the coinsurance for the vedolizumab. You say that this should be covered based 
on how you were previously billed another time for the same service. 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 20% 
coinsurance for each Medicare Part B prescription drug.  
 
 
 You have been asked to pay 20% coinsurance for the vedolizumab. This item/service falls within the Medicare 
Part B prescription drug 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 coinsurance for the 
vedolizumab (J3380) provided on April 27, 2023.