Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99223-AI) provided from November 6, 2022, 
through November 7, 2022. 
 
You asked the Plan to pay for initial hospital care. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the service is not supported by the records. 
 
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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit. 
 
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 initial hospital care. Our reviewer found the 
documentation does support code 99223 on November 6, 2022. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have been met. Therefore, we decided that the Plan has to 
pay for initial hospital care (99223-AI) provided from November 6, 2022, through November 7, 2022.  
 
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 bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the Plan does not cover the 
use of bone marrow aspirate for this procedure. Medical studies have not proven that this procedure is helpful 
for treatment of the enrollees health problem. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal stenosis of the cervical region and presented 
with continued numbness and burning pain to bilateral hands since the day of surgery. The pain is aggravated 
by cervical range of motion. The enrollee frequently drops things. The exam reveals intact strength, sensation, 
and reflexes. However, there is no specific indication provided to support the request for bone marrow aspirate 
for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine 
surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone 
marrow aspirate for this enrollees medical condition as discussed above. Therefore, the requested bone 
marrow aspirate (CPT 20939), in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on May 23, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the emergency room services based on Medicare criteria. Therefore, we decided that 
the Plan has to pay for the emergency room services provided on May 23, 2022.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the rehabilitation after having a stroke. You 
stated that you would not have anyone to help you once you are released. You stated that you need the rehab to 
regain maximum function. The Plan denied your request. The Plan says the request is not medically necessary, 
the services you need can be provided safely in other settings, for example, skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous angioplasty services. 
 
You asked the Plan to pre-approve the requested services. You say that the treatment is needed for your quality 
of life. The Plan denied your request. The Plan says you are not enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that a percutaneous transluminal angioplasty is only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The records do not indicate that you are enrolled in a Medicare 
approved clinical tria. Based on this information, we decided that Medicare rules for coverage of the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
angioplasty services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an IRF stay and close physician supervision, and you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says admission to an IRF is not medically 
necessary. 
 
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided on December 12, 
2022. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you do not agree with the cost 
sharing. 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. Your 
contract with the Plan says that you must pay a 10% coinsurance of the approved amount and the annual $800 
deductible applies, for doctor and other health care provider services. You have been asked to pay a cost share of $124.42 for the office visit ($124.42 allowed amount x .10 = $12.44 
coinsurance) ($12.44 coinsurance + $111.98 deductible = $124.42). The item or service you asked the Plan to 
waive the cost sharing for falls within the doctor and other health care provider services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which 
applies to doctor and other health care provider services. This cost sharing is a contractual obligation that had 
not been met at the time the office visit was provided on December 12, 2022. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the office visit provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve maxillary partial denture. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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. 
 
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 pre-approve 
maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #30 and retainer crowns 
(D6751) for tooth #28, #29, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat with the crowns. The Plan 
denied your request. The Plan says the denial of the bridge is correct because the implant planned for removal, 
as well as the poor condition of tooth #31 rendering it unsuitable as a bridge and recommends a removable 
partial denture. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the requested bridge is not medically necessary. Our physician reviewer found that tooth #30 has suffered 
extreme breakdown and had notable recurrent decay under the previous bridge. The amount of remaining 
coronal structure is minimal, and insufficient to aid in the retention of a bridge in the lower right quadrant. 
There is insufficient ferrule around the remaining tooth, which is a structural feature needed to ensure the tooth 
can properly act as an abutment in particular where a post support is necessary, as it would be in this case. 
Given the structure remaining on tooth #31 currently there would be no medical necessity for the requested 
bridge. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6241) for tooth #30 and retainer crowns (D6751) for tooth #28, #29, and 
#31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need the medical help because you have 
diabetes and high blood pressure. You also say that you are behind on utility bills for the past two months. The 
Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reclining chair. 
 
You asked the Plan to pre-approve a reclining chair. You say that you need this item because you had surgery. 
The Plan denied your request. The Plan says a recliner chair is a piece of furniture and is not used to treat a 
medical problem. Neither Medicare nor your health plan covers a recliner. 
 
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 pre-approve a reclining chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided from October 
5, 2022, to October 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the physician relies on the facility staff to 
obtain the necessary authorizations. You also say that the medically necessary services were rendered to the 
enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. 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 from October 5, 
2022, to October 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that this is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage 
requirements. 
 
The Plan follows Medicare rules. Medicare rules say that a high-frequency chest wall oscillation device can be 
covered if all criteria listed above is 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 a high frequency chest wall oscillation 
system. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
records in this case do not document the enrollee has a diagnosis of cystic fibrosis, bronchiectasis or a 
neuromuscular disease. 
 
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 high frequency chest wall oscillation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular gene panel billed for date of service 
September 10, 2021. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the testing is 
excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Routine screening and prophylactic testing for lipid disorders are not 
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular 
gene panel billed for date of service September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's mobility is limited, and you believe 
IRF services will strongly move the enrollee forward toward regaining function. The Plan denied your request. 
The Plan says the requested IRF services do not meet the requirements for approval. 
 
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service 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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain is unclear in this member. 
 
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.