Persius/hicric huggingface dataset:
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to provide medically 
necessary and reasonable treatment safely and effectively. Records do not document the need for intravenous 
medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There is no 
documentation that daily skilled services are required. You are walking household distances with a rolling 
walker with supervision and is supervision for transfers and minimum assist for activities of daily living. 
Provided records do not document a significant decline in your functional status compared to your recent 
baseline to necessitate daily inpatient skilled therapy services. There is no documentation that you require the 
services on an inpatient basis, only in a skilled nursing facility setting. Records support that services in the 
home with home health care or in a long-term care facility on a part time basis are appropriate in this case. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for November 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 is not supported by the medical 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 these services. Our reviewer says that procedure code 99285 
is not supported by the medical records. Our reviewer found the enrollee presented to the emergency 
department with palpitations after taking Viagra. Acute coronary syndrome was ruled out and other workup 
was unremarkable. The symptoms resolved after treatment with fluids and the enrollee was stable throughout. 
The records do not reveal a comprehensive history or physical and do not describe medical decision making of 
high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
December 1, 2020, through December 21, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the service should be covered. The Plan denied 
your request. The Plan says the claim must be submitted to the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directly 
contacted the provider to relay this information. As the secondary insurer, the Plan cannot be held responsible 
for the SNF services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on December 1, 2020, 
through December 21, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment services provided on December 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the provider is enrolled in the OTP program. 
The Plan denied your request. The Plan says that the code must be billed on the facility claim. 
 
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. 
 
We looked at the file and the rules. The submitted claim shows that the billing provider is the OTP facility. 
This was submitted on a professional claim which is allowed according to the billing guidelines. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the opioid treatment services provided on 
December 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary and 
will provide long-lasting pain relief. The Plan denied your request. The Plan says this is not an accepted 
standard of medical practice. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current peer-reviewed medical literature does not support that genicular 
artery embolization has been shown in controlled studies in an approved medical journal to result in long-term 
health benefits in patients with osteoarthritis of the knee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the percutaneous image-guided breast biopsy rendered on November 
15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that image-guided breast biopsy is covered when 
specific criteria 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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee had a retroareolar right breast 
mass and was favored to represent gynecomastia. The area showed increased fluorodeoxyglucose (FDG) 
activity on positron emission tomography (PET)/computed tomography (CT) and the enrollee is awaiting a spot 
on the transplant list. The pathology results confirm that the mass is consistent with benign gynecomastia. The 
records support that the biopsy was reasonable and medically necessary to rule out malignancy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan has to pay 
for the percutaneous image-guided breast biopsy rendered on November 15, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission based on the enrollee's condition and your strong 
recommendation that LTACH is the most appropriate level of care for this enrollee. The Plan denied your 
request. The Plan says criteria for admission to the LTACH have not been met. 
 
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. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated scooter (K0800). 
 
You asked the Plan to pre-approve a power operated scooter. You say that the requested power operated 
scooter is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power operated scooter. Our reviewer says that a power operated scooter is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate the enrollee requires a power mobility device to complete mobility related 
activities of daily living (MRADLs). Therefore, the reviewer found that a power operated scooter 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 a power operated scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated scooter (K0800).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the external mobile cardiovascular telemetry with electrocardiographic 
recording and concurrent computerized real time data analysis provided on April 27, 2022, billed with code 
93229. 
 
You asked the Plan to pay for the mobile cardiovascular telemetry services. You say that this was medically 
necessary and should be paid. The Plan denied your request. The Plan says that the submitted medical records 
include the set up and start of technical monitoring information; however, this is not the billed date of service. 
The Plan indicates that this date discrepancy means the claim cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's denial rationale is not supported. The billed date of 
service is noted to be the date on which the cardiac data was analyzed by the provider. The Plan has not 
provided any citation that indicates that the analysis date is not appropriate to report as the date of service. We 
found no coding guidance which suggests that another date should be used to report this service. As such, we 
find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the 
external mobile cardiovascular telemetry with electrocardiographic recording and concurrent computerized real 
time data analysis provided on April 27, 2022, billed with code 93229.  
 
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 pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that if the enrollee does not have this there may be 
hospitalization. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20553 for date of service December 23, 
2022. 
 
You asked the Plan to pay for procedure code 20553. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 20553 is injection(s); single or multiple trigger point(s), 3 
or more muscles. 
 
 
 
 We find that CPT code 20553 is not supported in the medical record. Specifically, the medical records do not 
indicate that a minimum of three muscles were injected. Based on this information, we decided that Medicare 
rules for coverage of procedure code 20553 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 20553 for date of service December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80061) provided on October 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services 
(80061) provided on October 26, 2022.
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 appealing with supporting records. 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 the enrollees 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Semaglutide (Weight Mngmt) Soln Auto-Injector, a 
self-administered drug. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the member has a history of chronic 
obesity. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare 
Part A or Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Semaglutide (Weight 
Mngmt) Soln Auto-Injector, a self-administered drug.  
 
Benefits for a self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an in-network provider at an out of 
network (OON) facility for a total hip surgery. 
 
You asked the Plan to pre-approve continued care with an in-network provider at an OON facility. You say that 
you have been the enrollee's doctor for over eight years and the enrollee does not want to see another provider 
for the procedure. The OON hospital used to be in-network, but they are now OON. The provider is not on staff 
at the in-network hospitals. The Plan denied your request. The Plan says the services can be provided by an in-
network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued care with an in-network 
provider at an OON facility. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the medical records show the enrollee has hip DJD. This may be safely treated by an in-plan 
fellowship trained hip orthopedic surgeon. There is no need for an OON referral. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued care with an in-network provider at an OON facility have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continued care with an in-network 
provider at an out of network (OON) facility for a total hip surgery.