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

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires more than 6.5 hours 
of care. The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute 
care and does not require 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 that the enrollee appears to be improving with the current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until the 
enrollee is more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to the 
LTACH is not medically necessary as it would not be clinically advantageous 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 long-term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance response and treatment 
provided on March 20, 2023. 
 
You asked the Plan to waive the copayment for the ambulance response and treatment. You say that you cannot 
afford the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for ambulance services. 
 
You have been asked to pay a $270 copayment for the ambulance response and treatment. This item/service 
falls within the ambulance services 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. However, since the allowed amount is less than the standard copayment, you 
only owe $250. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
response and treatment provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve craniotomy or craniectomy with implant stimulator in 
brain (DBS placement) (61867, 61868). 
 
You asked the Plan to pre-approve DBS placement. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has documentation of depression and schizophrenia; therefore, DBS 
placement is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that DBS can be covered under certain conditions. 
 
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 DBS placement. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found medical records in this case document the 
enrollee has mild cognitive impairment, mild hallucinations and psychosis and moderate depressed mood with 
no clarification from the involved medical providers that these issues would not be worsened by or would not 
interfere with the patient's ability to benefit from DBS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DBS placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve craniotomy or craniectomy with implant stimulator in brain (DBS placement) (61867, 
61868).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the acne surgery provided on April 26, 2023. 
 
You asked the Plan to pay for the acne surgery. You say that the acne surgery was medically necessary. The 
Plan denied your request. The Plan says that the acne surgery is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acne surgery. Our reviewer says that the 
requested acne surgery is considered medically reasonable and necessary in this case. Our physician reviewer 
found the acne surgery is medically necessary based on the community standards 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 acne surgery have been met. Therefore, we decided that the Plan has to pay for 
acne surgery provided on April 26, 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: 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. You say that it is not safe to discharge the enrollee home as they 
require additional inpatient care. The Plan denied your request. The Plan says the enrollee's records do not 
show that they need skilled physical therapy on a daily basis in an inpatient setting. 
 
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 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 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 pre-approve a FreeStyle Libre 2 sensor kit.  
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor kit. The Plan denied your request. The Plan says 
the conditions for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 2 sensor kit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that services were provided in good faith. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on March 28, 2023, billed with 
procedure codes 99204-25-GA and 76881-RT-GA.  
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 99204-25-GA and 76881-RT-GA is office or other 
outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate 
history and/or examination and moderate level of medical decision making. When using time for code 
selection, 45-59 minutes of total time is spent on the date of the encounter, and ultrasound, complete joint (ie, 
joint space and peri-articular soft-tissue structures), real-time with image documentation.  
We asked our coder 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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the procedure report does not include 
sufficient documentation to support, medically appropriate history and/or examination and moderate decision 
making (99204). Procedure code 76881 was not documented, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on March 28, 2023, billed with procedure codes 99204-
25-GA and 76881-RT-GA.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is currently receiving appropriate care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 26, 2023, billed 
with evaluation and management (EM) code 99236.  
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded.  
 We asked our coder 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that this procedure cannot be verified, due 
to claim was incorrectly reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 26, 2023, billed with evaluation 
and management (EM) code 99236.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interbody biomechanical device(s) with 
integral anterior instrumentation for device anchoring, when performed, to intervertebral disc space in 
conjunction with interbody arthrodesis, each interspace (22853), posterior non-segmental instrumentation 
(22840), and arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612). 
 
You asked the Plan to pre-approve insertion of interbody biomechanical device(s) with integral anterior 
instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace, posterior non-segmental instrumentation, and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Medicare criteria for reasonable and necessary are not met because use of this 
device as a stand-alone procedure has not been shown to be safe and effective in long term studies 
 
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 of interbody biomechanical 
device(s) with integral anterior instrumentation for device anchoring, when performed, to intervertebral disc 
space in conjunction with interbody arthrodesis, each interspace, posterior non-segmental instrumentation, and 
arthrodesis, posterior or posterolateral technique, single interspace; lumbar. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. 
 
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 of interbody biomechanical device(s) with integral anterior 
instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with 
interbody arthrodesis, each interspace, posterior non-segmental instrumentation, and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of interbody biomechanical device(s) with integral anterior instrumentation 
for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, 
each interspace (22853), posterior non-segmental instrumentation (22840), and arthrodesis, posterior or 
posterolateral technique, single interspace; lumbar (22612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is unclear as the magnetic resonance imaging shows facet 
degenerative joint 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. 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 dental services D6240 and D6750 are 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 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 service is not medically necessary. Our physician reviewer found being that the teeth indicated for 
pontics are present and the teeth indicated for retainer crowns are missing, the documentation does not coincide with the proposed treatment.  A more comprehensive treatment plan addressing the other missing teeth is in the 
best interest of the patient. 
 
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 the dental services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were ordered by a treating 
physician. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 29, 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 the intensity of a 
multidisciplinary rehabilitation program to progress and return to the community. The Plan denied your 
request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 have complex or intensive rehabilitation needs and does not 
require frequent physiatry oversight. The enrollee does not have any medical barriers to standard post-acute 
rehabilitation. The enrollee's level of function may be reasonably addressed at a skilled nursing facility or home 
care level.  
 
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.