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 the enrollee needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet 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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do 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 medical record supports a need for skilled 
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 at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve this OON item. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not covered when provided by an OON 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 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 
a wheelchair 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 procedure code 99308 and 99309 billed for dates of service 
April 7, 2023, to April 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that additional dates of service were billed on the 
same claim. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99308 and 99309 are not supported in the medical record. The records provided note 
an admission date of July 15, 2023. The records do not clearly document the date the services were provided. 
The Plan did make multiple attempts to obtain additional information, but non were obtained. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99308 and 99309 billed for dates of service 
April 7, 2023, to April 24, 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 needs this care to regain function and 
mobility. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria 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 complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the knee orthosis (L1832), and condylar pad (L2810), 
provided on October 5, 2022. 
 
You asked the Plan to hold you harmless for the knee orthosis and condylar pad. You say that the items should 
be covered. The Plan denied your request. The Plan says that the items are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the knee orthosis and condylar pad by a contract provider. The file does not show that 
the Plan provided notice that the knee orthosis and condylar pad would not be covered. Under Medicare rules, 
this means the knee orthosis and condylar pad is considered approved by the Plan. Therefore, we decided that 
the Plan has to hold you harmless for the knee orthosis (L1832), and condylar pad (L2810), provided on 
October 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture (D0364) 
provided on June 30, 2023. 
 
You asked the Plan to pay for the cone beam CT capture. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture (D0364) provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ procedure. 
 
You asked the Plan to pre-approve the LinQ procedure. You say that the LinQ procedure is needed to properly 
address the level of pain. The Plan denied your request. The Plan says the requested LinQ device is still being 
studied to see if the treatment is reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LinQ procedure. Our reviewer says 
that the requested LinQ procedure is not considered medically reasonable and necessary. Our physician 
reviewer found you have chronic low back pain and had bilateral sacroiliitis. You have had physical therapy 
and chiropractic therapy. Your medication trials have included opiates, Gabapentin, Lyrica, muscle relaxants 
and Tylenol. You had right LinQ procedure with 100% pain relief. The LinQ procedure is considered experimental/investigational therapy and it is the subject of ongoing clinical trials.  Therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LinQ procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LinQ procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the enrollee has completed a 24-
hour Holter monitor that showed no atrial fibrillation. You also say that the enrollee has completed a 30-day 
event monitor that did not show atrial fibrillation. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the enrollee has a history of documented atrial fibrillation, there is 
no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an ILR. Therefore, the reviewer found that the requested ILR procedure is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide skilled nursing and home health aide visits. 
 
You asked the Plan to provide home health services. You say that these services are necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
  The file does not show that you are homebound. Therefore, we decided that the Plan does not have to provide 
skilled nursing and home health aide visits.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided on March 3, 2023 to March 8, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that the benefit was exhausted. 
 
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. The plan did not cite the relevant Medicare rule or policy used to render their 
determination.  Therefore, we decided that the Plan has to pay for inpatient hospital care provided on March 3, 
2023 to March 8, 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: 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 needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet 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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do 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 medical record supports a need for skilled 
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 at a lower 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: 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 IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria 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 enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do 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 medical record supports a need for skilled 
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 at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot insert, foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
insert, foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 1 heavy-duty, patient 
weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve power operated vehicle. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are 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 pre-approve power operated vehicle. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you have a personal mobility deficit that impairs participation in 
mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary 
locations within the home. There is no documentation that your mobility deficit cannot be helped by the use of 
a walker, cane or manual wheelchair. Based on the medical records provided there is no documentation that 
you can safely operate a power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power operated vehicle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 
pounds (K0801).
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the records do not show that the enrollee needs to be 
seen by a rehabilitation doctor 3 times a week. The records do not 
show that the enrollee needs an intensive team for your 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 enrollee does not meet CMS coverage criteria for IRF admission. The enrollee is 
medically stable and does not need a physical medicine and rehabilitation physicians supervision 3 times a 
week in an IRF. At the current functional level, the enrollee needs physical therapy and occupational therapy 
and does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. The documentation does not support the necessity for admission to 
an IRF. The complexity of the enrollees medical, rehabilitation, and nursing needs  does not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollees 
rehabilitation 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of Q0092 rendered on June 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider only did 4 x-rays and 1 electrocardiogram (EKG). 
 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 Q0092 is "Set-up portable x-ray equipment." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that on this date of service, 2 views 
cervical spine, 2 views thoracic spine, 2 views sacrum and coccyx and 3 views lumbar spine were done for a 
total of 4 x-ray exams and then an electrocardiogram (EKG) was done. The portable x-ray company cannot bill 
a fifth charge for a non radiologic exam. The billing is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for five units of Q0092 rendered on June 12, 2023.