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

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient hospital care is 
medically necessary. The Plan denied your request. The Plan says the requested spine surgery is approved but 
the inpatient admission for inpatient level of care is not met and not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the record indicates that the enrollee is scheduled for Lateral Discectomy 
Lumbar 3-4, and Extreme Lateral Interbody Fusion Lumbar 3-4. The record provided does not indicate that the 
treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights, taking into 
account complex medical factors. The initial day may be spent in observation until it is clearly expected that a 
second midnight would be required, at which time the physician may order inpatient admission. The elements 
of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 2, 2022, billed with 
code 87798-XU. 
 You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
codes 87150 and 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87798 is a column II code to column I codes 87150 and 87801; 
however, 87798 was billed with a modifier.  
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the laboratory report does not include 
documentation to support an unusual non-overlapping procedure 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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on November 2, 2022, billed with code 87798-XU.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered on 
September 16, 2021.  
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 has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in any five day MDS assessment for these services. This document is necessary to verify 
these services.. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) 
services rendered on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided April 25, 
2022, to May 5, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe these services were 
medically necessary and the medical records do support the use. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
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. 
 
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 a pneumatic compression device (E0675) provided April 25, 2022, to May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for total knee arthroplasty (TKA) (27447) provided January 6, 
2023. 
 
You asked the Plan to pay for the surgical procedure. You say that the out of network provider was the only 
available assistant at the time of the procedure and rendered services specifically requested by the in network primary physician and in network facility. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. This 
provider was not certified with Medicare to be paid for this procedure. 
 
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 total knee arthroplasty (TKA) (27447) 
provided January 6, 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 has had a series of Afib attacks and 
unable to get under control with medication. The Plan denied your request. The Plan says the available records 
for the enrollee does not meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 1, 2022, to March 
30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SBRT services (77373). 
 
You asked the Plan to pre-approve SBRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 SBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that SBRT could conceivably be quite risky in treatment of a long bone with respect to fracture, given 
the escalated dose that is used. SBRT could provide additional risks with no benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SBRT services (77373).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial acromioplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the partial acromioplasty is not considered medically necessary for any reason. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Additionally, there is limited published, large-scale, long-
term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested partial acromioplasty, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve partial acromioplasty.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283) provided on November 
24, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this provider is not eligible for Medicare payment. 
 
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 emergency room services (99283) 
provided on November 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 dental 
services on February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to 
April 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to April 
10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says Botox has been prescribed for an off-label, not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that treatment 
with Botox is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Botox is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-bed table, 2 bathtub wall rails, 2 Tylenol extra 
strength, electric toothbrush, commode liner, with pad, commode pads, commode lines, button hook zipper 
pull, comfort wipes, and 2 wheelchair ramps provided from December 15, 2021, to January 8, 2022. 
 You asked the Plan to pay for the items and supplies. You say that you had back surgery. You say that you 
cannot use stairs and need a table to eat on. You say that you can barely lift your arms. You also say you were 
informed these things are reimbursable. The Plan denied your request. The Plan says these items are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered, it must primarily 
serve a medical purpose.  The rules say that Medicare does not pay for OTC items and Tylenol extra strength is 
an OTC item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the items and supplies have not been met. Specifically, the over-bed table, bathtub wall rails, 
electric toothbrush, commode liner, with pad, commode pads, commode lines, button hook zipper pull, comfort 
wipes, and 2 wheelchair ramps do not serve a medical purpose. Additionally, Tylenol extra strength is an over-
the-counter item and thus is not covered. Therefore, we decided that the Plan does not have to pay for the over-
bed table, 2 bathtub wall rails, 2 Tylenol extra strength, electric toothbrush, commode liner, with pad, 
commode pads, commode lines, button hook zipper pull, comfort wipes, and 2 wheelchair ramps provided from 
December 15, 2021, to January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on November 9, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says the services in this case are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made unless auxiliary 
personnel furnish acupuncture under the appropriate level of supervision of a physician, physician assistant 
(PA), or nurse practitioner (NP)/clinical nurse specialist (CNS).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acupuncture services have not been met. The record does not support that the provider in this 
case was under the appropriate level of supervision. Therefore, we decided that the Plan does not have to pay 
for the acupuncture services provided on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio device provided on December 30, 2022. 
 
You asked the Plan to pay for the Cala Trio device. You say that the enrollee has been seeing improvement and 
control over her hands' essential tremor while using this device. You also say that this should be covered. The 
Plan denied your request. The Plan says this device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that use of electric nerve stimulation in the treatment of 
motor function disorders, such as multiple sclerosis, is a recent innovation, and the medical effectiveness of 
such therapy has not been verified by scientifically controlled studies. 
 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 the Cala Trio device. Our reviewer says that 
the Cala Trio device is not medically necessary. Our physician reviewer found the Cala Trio device is not 
considered reasonable and necessary to treat motor function disorders as the medical effectiveness of such 
therapy has not been verified by scientifically controlled studies. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cala Trio device provided on December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27326 and 99222 rendered on April 19, 
2022. 
 
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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 27236: 
 
Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement 
 CPT 99222: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of 
moderate 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 problem(s) requiring admission are of moderate severity. Typically, 50 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
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 in terms of CPT 27236, the 
medical record includes several copies of a report stating, "Please see operative note below for 
details." However, the documentation does not include an operative report, and therefore this procedure cannot 
be verified. In terms of CPT 99222, the procedure report supports the history was only focused. Therefore, the 
records do not support this billed service. 
 
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 procedure codes 27326 and 99222 rendered on April 19, 2022.