Persius/hicric huggingface dataset:
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 you prefer to admit to acute rehab because you were 
independent before hospitalization, and want to return to being independent and eager to participate in the 3 
hours of aggressive rehabilitation that will be offered. The Plan denied your request. The Plan says your 
condition does not meet the Medicare guidelines.  The Plan says that the services needed may be provided 
safely in a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
bitewings (D0274), and an adult prophylaxis (D1110) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you assumed you would be covered under your 
dental Plan since y9ou had been seeing this provider for so long. The Plan denied your request. The Plan says 
the dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an intraoral - periapical first radiographic image (D0220), bitewings (D0274), and an adult 
prophylaxis (D1110) 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 inpatient rehabilitation is the coarse of treatment 
necessary to help the enrollee return to daily activities and regain independence. The Plan denied your request. 
The Plan says the enrollee's condition does not meet the Medicare guidelines.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on December 29, 2022, to 
January 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for inpatient hospital care. You say that the services should be covered. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 inpatient hospital care provided on December 29, 
2022, to January 2, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral mandibular advancement device (OMAD)(E0486). 
 
You asked the Plan to pre-approve an oral mandibular advancement device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that there was not clear evidence to support a 
contraindication to the enrollee's use of her positive airway pressure (PAP) device, it was noted that her 
compliance with the PAP is adequate and that she is benefiting from it, despite her chronic sinus issues.  
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated mandibular advancement oral 
appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered if criteria A - D 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 an oral mandibular advancement 
device. Our reviewer says that the item is medically necessary. Our physician reviewer found a home sleep 
study on November 30, 2021, showed an apnea-hypopnea-index (AHI) of 25.2. Medicare criteria for approval 
of an OMAD does not require intolerance of continuous positive airway pressure (CPAP) if the AHI is less 
than 30.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral mandibular advancement device have been met. Therefore, we decided 
that the Plan has to pre-approve an oral mandibular advancement device (OMAD)(E0486).  
 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 the walker (E0143), purchased on March 19, 2023. 
 
You asked the Plan to pay for the walker. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0143), purchased on March 
19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home evaluation (99349) provided on May 09, 2023. 
 
You asked the Plan to pay for the home evaluation (99349). You say that the service was 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 home evaluation 
(99349) provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anticoagulant management services provided on July 12, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the anticoagulant management services. You say that this is supported in the 
records. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 anticoagulant management services provided 
on July 12, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU system) (E0217). 
 
You asked the Plan to pay for the VCU. You say that the item was medically necessary. The Plan denied your 
request. The Plan says this item was used for preventative services. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  If code E0215 or 
E0217 is provided it will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the vascular compression unit (VCU system) (E0217).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance service, advanced life support, emergency 
transport, (A0427) and ground mileage, per statute mile (A0425) provided on March 17, 2023. 
 
You asked the Plan to pay for an ambulance service. You say that you are requesting reconsideration for 
payment on this claim. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 5, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for an ambulance service have not been met. Therefore, 
we decided that the Plan does not have to pay for an ambulance service, advanced life support, emergency 
transport, (A0427) and ground mileage, per statute mile (A0425) provided on March 17, 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 these services are medically necessary for the 
enrollee to regain their independence. The Plan denied your request. The Plan says these services can be 
obtained at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA 1/2 panel provided on April 12, 2023, and 
billed with codes 81432 and 81433. 
 
You asked the Plan to pay for the Invitae BRCA 1/2 panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Invitae BRCA 1/2 panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the Invitae BRCA 1/2 panel provided on 
April 12, 2023, and billed with codes 81432 and 81433.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography cerebral perfusion analysis 
(0042t) 
 
You asked the Plan to pay for computed tomography cerebral perfusion analysis. You say that the service was 
medically necessary. The Plan denied your request. The Plan says  there is no documentation of an acute 
ischemic stroke caused by unilateral large vessel occlusion in the proximal anterior circulation. 
 
The Plan must follow Medicare rules. Medicare rules say that computed tomography cerebral perfusion 
analysis (CTP) (using automated postprocessing software algorithmic analysis) is medically reasonable and necessary in patients with acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the 
proximal anterior circulation evaluated at stroke centers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of computed tomography cerebral perfusion analysis have not been met. Therefore, we decided that 
the Plan does not have to pay for the computed tomography cerebral perfusion analysis (0042t)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination provided on March 29, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for a radiologic examination. You say that the services should be covered. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The 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 a radiologic examination provided on March 29, 
2023, 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 subsequent nursing facility care provided on April 7, 
2023, by an OON provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on 
April 7, 2023, by an OON provider.
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 you prefer to admit to acute rehabilitation because 
you were independent before hospitalization and want to return to being independent. You are eager to 
participate in the three hours of aggressive rehabilitation that you will not get that in a nursing 
home setting. The Plan denied your request. The Plan says your condition does not meet the Medicare 
guidelines and has not completed the full course of treatment in the referring hospital.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 due to your health, you feel you could be better 
treated at an inpatient facility. The Plan denied your request. The Plan says this 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 On review of 
the                                                                                                                                                                              
                                                                                                                                                                                   
                                                                                                                                                                                   
                                                                                                                                                     On review of the 
available records, the enrollee with history of Debility from acute illness as described above does not meet the 
CMS coverage criteria for an IRF admission. 
The enrollee is medically stable and does not need, medical monitoring by PM&R physician with close 
supervision for conditions described above 3 times per week (at a minimum). 
The enrollee needs continued PT and OT and does not need 3 hours a day x 5 days a week of therapies with 
multidisciplinary approach in an IRF. 
Document does not support medical necessity for admission to an IRF. The enrollee has no medical complexity 
currently with no acute rehab nursing needs to warrant an admission to an IRF. 
While the enrollee would benefit from PT and OT the enrollees rehab needs can be safely provided in an 
alternate and low intensity setting such as in an SNF.  
 
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.