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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has pain with movement and 
will benefit from skilled therapy. The Plan denied your request. The Plan says additional therapy is not 
medically necessary. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the PT note from June 16, 2023, states that the enrollee feels a 
little better than before; however, the prior level of function and current functional level is not clear. The 
documentation is also not clear how much prior therapy the enrollee has had. Without this information, it is not 
clear that the enrollee requires ongoing formal therapy or why they are unable to participate in a home exercise 
program.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and consultations (99205, 99215, 88321) 
for surgical oncologist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and consultations. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says you must use network providers to 
get health care and services when there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and consultations (99205, 99215, 88321) for surgical oncologist to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on January 18, 2023. 
 
You asked the Plan to pay for the debridement. 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 debridement 
provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 30, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were highly 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 the office visit provided 
on March 30, 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 enrollee requires an IRF admission to regain 
maximum function. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for an IRF admission. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service September 1, 
2022, to September 4, 2022.  
 
You asked the Plan to pay for procedure code 99221. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99221 is bundled into payment for code 
99222. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99221 
is a column II code to column I code 99222 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99221 billed for date of service September 1, 2022, to 
September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a hormone specialist to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you must use network providers for most 
services. The service requested is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) with a hormone specialist to be provided by an out-of-network (OON) provider.
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 to get out of bed, you still require extensive hands-on 
assistance from the nursing and therapy staff. You also say your provider says you will need closer medical 
management of your current medical needs and disease. 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 your nursing, medical, and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical records 
provided do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy 
at a lower level of care such as in a skilled nursing facility is not appropriate for you. There is no support in the 
documentation that you require the intensive medical care and 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are having trouble walking and require IRF 
services to regain your prior level of functioning. The Plan denied your request. The Plan says the request 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and 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 you would like reconsideration based on the records.  
The Plan denied your request. The Plan says an IRF admission 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 enrollees 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 pay for Infrared light therapy provided on February 6, 2023. 
 
You asked the Plan to pay for Infrared light therapy. You say that other claims for the same services have been 
paid by the Plan. The Plan denied your request. The Plan says this service in a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on February 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93926 billed for date of service March 15, 
2023.  
 
You asked the Plan to pay for procedure code 93926. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93926 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing the bilateral code for this service. You did not provide 
all the required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
93926 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93926 
billed for date of service March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0973, E0978, E1007, E1012, E2361, 
K0040, E1028, E2311, E2313, E2377, E2343, E0955, E0956, E2609, and E2617). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that without the medically necessary custom seating system, the enrollee is at a high repeated falls 
risk/injury risk as well as an advancement of postural deformities and skin breakdown as a result of using a 
non-custom seating system. The Plan denied your request. The Plan says the enrollee does not have a medical 
need for multiple power options included with K0861 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) 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 enrollee does not meet the coverage criteria for 
the requested power wheelchair base. Our physician reviewer found the enrollee does not have high risk for 
skin breakdown, use a catheter intermittently, have spasticity, require an alternative means of managing power 
drive, or use a ventilator.  
 
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 multiple power options (K0861) and additional items and accessories (codes E0973, E0978, 
E1007, E1012, E2361, K0040, E1028, E2311, E2313, E2377, E2343, E0955, E0956, E2609, and E2617).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine billed with code J3490 for date of service 
September 30, 2022. 
 
You asked the Plan to pay for Bupivacaine billed with code J3490. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says per the documentation Bupivacaine was bundled in the 
procedure; therefore, it cannot be billed again separately. 
 
The Plan must follow Medicare rules. Medicare rules say that some services are included within the procedure 
and are therefore, not separately payable.  
 
We looked at the file and Medicare rules. Review of the file shows that Bupivacaine was used but is bundled in 
the procedure also provided on the same date (procedure codes 20610 and J7321). This means code J3490 is 
not separately payable as billed. Based on this information, we decided that Medicare rules for coverage of Bupivacaine billed with code J3490 have not been met. Therefore, we decided that the Plan does not have to 
pay for Bupivacaine billed with code J3490 for date of service September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E1012, E2359, E1028, E2300, 
E2311, E2313, E2377, E0955, E2620, and E2622). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with K0861 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee does not have a qualifying diagnosis of congenital spinal 
abnormality, neurological disease or myopathy nor do they have high risk for skin breakdown, use a catheter 
intermittently, have spasticity, or require an alternative means of managing power drive. 
 
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 multiple power options (K0861) and additional items and accessories (codes E1007, E1012, 
E2359, E1028, E2300, E2311, E2313, E2377, E0955, E2620, and E2622).