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

 
We decided that the Plan does not have to pre-approve the SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to return home because they 
need more rehabilitation and observation services. The Plan denied your request. The Plan says the enrollee has 
no daily skilled nurse or therapist needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs. There are also no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 the SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and care planning services provided on 
August 22, 2023. 
 
You asked the Plan to pay for an office visit, and care planning services. You say that these services were 
medically necessary. 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 an office visit, and care 
planning services provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 02, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on May 02, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81456 provided on April 25, 2023. 
 
You asked the Plan to pay for procedure code 81456. 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. 
 
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 81456 based on Medicare criteria. The Plan has provided no evidence to support 
that procedure code 81455 was billed and paid for on the same date of service as procedure code 81456. 
Therefore, we decided that the Plan has to pay for procedure code 81456 provided on April 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug-delivery system (A4305) and infusion 
supplies (A4223) provided from June 25, 2023, to July 1, 2023. 
 
You asked the Plan to pay for a disposable drug-delivery system and infusion supplies. You say that the items 
at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says the items at issue 
are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug-delivery systems are non-
covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and 
supplies used with disposable drug delivery systems are also non-covered items. Based on this information, we 
decided that Medicare rules for coverage of a disposable drug-delivery system and infusion supplies have not 
been met. Therefore, we decided that the Plan does not have to pay for a disposable drug-delivery system 
(A4305) and infusion supplies (A4223) provided from June 25, 2023, to July 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 21, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 21, 
2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care, which has been supported by the hospital 
staff as next steps, will increase the ability for the enrollee to be able to perform independent living tasks. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for SNF care. 
 
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 there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64450-59 billed for date of service March 16, 2023. 
 
You asked the Plan to pay for the billed code. You say that medical records were provided. The Plan denied 
your request. The Plan says that the code is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 64450 is supported. The records show that the enrollee received general anesthesia 
(code 01402) for knee surgery. The Plan has not shown that the adequacy of the intraoperative anesthesia was 
depended on nerve block injection code 64450. An epidural or peripheral nerve block injection for 
postoperative pain management in those receiving general anesthesia may be administered preoperatively, 
intraoperatively, or postoperatively. Based on this information, we decided that Medicare rules for coverage of 
the billed code have been met. Therefore, we decided that the Plan has to pay for procedure code 64450-59 
billed for date of service March 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on June 4, 2022. 
 
You asked the Plan to pay for the non-emergent services. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the claim was not filed within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the non-emergent services was not filed until June 9, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for non-emergent ambulance services provided on June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98941 provided on August 23, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 98941 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure code 98941 provided on August 23, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to noble metal for tooth 
#11, #13 (D6752) and a pontic for tooth #12 (D6242). 
 
You asked the Plan to pre-approve retainer crown and pontic. You say that you need this so you can chew your 
food properly. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 retainer 
crown and pontic 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 pre-approve retainer crown and pontic. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the x-rays show that the enrollee 
is missing all their molars and tooth #12 is present in the x-rays. D6752 (retainer crown- porcelain fused to noble metal) for teeth #11,13 and D6242 (pontic- porcelain fused to noble metal) for tooth #12 are not 
medically necessary since tooth #12 is present. There is no clinical documentation that states tooth #12 is no 
longer present. 
 
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 retainer crown and pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown - porcelain fused to noble metal for tooth #11, #13 (D6752) 
and a pontic for tooth #12 (D6242).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for 
treatment of central sleep apnea (0424T). 
 
You asked the Plan to pre-approve insertion or replacement of neurostimulator system for treatment of central 
sleep apnea. You say that this is medically necessary. The Plan denied your request. The Plan says the records 
do not show the enrollee requires an alternative to management of respiratory insufficiency because of 
dependency upon the usual therapy of intermittent or permanent use of a mechanical ventilator. The request 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 insertion or replacement of 
neurostimulator system for treatment of central sleep apnea. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the records 
do not provide any downloaded data on compliance and effectiveness of continuous positive airway pressure 
(CPAP).  The records do not show the patient has been tried on bilevel positive airway pressure (BiPAP) or 
adaptive-servo-ventilation. The Remede System is not a widely accepted and recommended treatment for 
central sleep apnea. The preferred treatment is CPAP, and if that fails, BiPAP or adaptive-servo 
ventilation. There is no documentation of CPAP failure or complete intolerance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of neurostimulator system for treatment of central 
sleep apnea have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or 
replacement of neurostimulator system for treatment of central sleep apnea (0424T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0953, E0955, E1002, E1028, E2310, E2363, and 
E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that this enrollee qualifies and should be approved for a K0856 Group 3 power wheelchair with 
accessories. The Plan denied your request. The Plan says a Group 3 standard power wheelchair with single 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) and 
additional items and accessories (codes E0953, E0955, E1002, E1028, E2310, E2363, and E2620). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with single 
power option (such as code K0856) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has a neurologic disorder with functional deficits.  The documentation 
does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the 
bladder or have spasticity that would necessitate power tilt or recline. Our reviewer also found that although the 
enrollee's condition may meet criteria for a power wheelchair, the criteria for this specifically requested power 
wheelchair are not met. 
 
 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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0953, E0955, 
E1002, E1028, E2310, E2363, and E2620).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87801 provided on July 14, 2023. 
 
You asked the Plan to pay for procedure code 87801. 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 their denial 
of payment for procedure code 87801 based on Medicare criteria. The Plan references Local Coverage 
Determination (LCD) L39003 and Local Coverage Article (LCA) A58726 as the basis of their denial stating 
the diagnosis code billed is not covered under the LCA and LCD. However, the file shows that the laboratory 
services were provided in the state of Colorado. This means that L39003 and A58726 are not within the correct 
jurisdiction and are not binding in this case. Therefore, we decided that the Plan has to pay for procedure code 
87801 provided on July 14, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy services. You say that the provider for the services is closer 
to your home. The Plan denied your request. The Plan says these services can be provided from an in-network 
provider. 
 
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 physical therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no indication that you could not get prior authorization for the services or that 
you could not receive equally beneficial services from an in-network provider. The requested outpatient 
physical therapy services are 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a Group 1 heavy duty power operated vehicle. You say that it is medically 
necessary for this patient to have a heavy-duty power chair to help with their activities of daily living. You also 
say that the scooter will be used indoors and outdoors. The Plan denied your request. The Plan says the patient 
does not meet the Medicare guidelines for a power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 Group 1 heavy duty power operated 
vehicle. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation available for review does not support that the patient requires a power mobility device to 
accomplish mobility related self-care tasks in the home. Our reviewer also found that there is no indication they 
are unable to use an alternative assistive device. 
 
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 Group 1 heavy duty power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (K0801).