Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatherapy at an out-of-network facility with a 
saltwater pool. 
 
You asked the Plan to pre-approve aquatherapy at an out-of-network facility. You say that you need help 
finding a physical therapy that offers water therapy. You also say that the place you have gone to before does 
not accept your insurance anymore. The Plan denied your request. The Plan says there is an in-network 
provider within two miles of the enrollee's home that can provide aquatherapy. The Plan also says that there are 
no documented benefits of saltwater aquatherapy as compared to traditional chlorinated water aquatherapy. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
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 aquatherapy at an out-of-network 
facility. Our reviewer says that aquatherapy in a saltwater pool at an out-of-network facility is not medically 
necessary. Our physician reviewer found the plan is offering adequate care to meet your medical needs through 
referral to a network physical therapy facility. The reviewer found that the documentation does not reveal 
anything unique about your condition that that would make it medically necessary for you to see the requested 
out-of-network provider. The reviewer found that the plan has shown that they have in-network providers who 
meet the Standards of Care required for treatment of your condition. The reviewer also found that it is not 
medically necessary for you to receive aquatherapy in a saltwater pool versus a chlorinated pool. Therefore, the 
reviewer found that the requested aquatherapy at an out-of-network facility 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 aquatherapy at an out-of-network facility have not been met. Therefore, we 
decided that the Plan does not have to pre-approve aquatherapy at an out-of-network facility with a saltwater 
pool.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 22, 2022, to 
February 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree that the claim date 
and the NOA date must match. 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 January 22, 2022, to 
February 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 acupuncture sessions. 
 
You asked the Plan to pre-approve 28 acupuncture sessions. 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 must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, your lower back pain has an identifiable systemic 
cause and therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-
approve 28 acupuncture sessions.
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 this admission is 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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status.  The enrollee can receive further services 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve extractions for tooth #22, #23, #24, #25, #26, and #27 and benign 
tumor. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested dental services are 
not covered by Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested dental services meet the criteria for coverage. Our physician reviewer found that while 
Medicare does not cover dental services, the Plan offers this supplemental dental benefit, and therefore the 
determination is based not on Medicare rules but on the supplemental dental benefits as they are laid out in the 
contract documentation provided to the QIC. While the Plans case file may say that they dont cover tooth 
extractions, thats not what the contract information they provided to the QIC says. The Plan did not provide 
the QIC with a Dental Plan Information Guide. The EOC lists extractions and oral surgery for the excision of 
hyperplastic tissue as covered benefits. There are no exceptions or limitations clearly explained in the contract 
information they provided. The benign tumor and tori described would meet the definition of hyperplastic 
tissue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve extractions for tooth #22, #23, #24, #25, #26, and #27 and benign tumor.  
  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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 You asked the Plan to pre-approve Darzalex Faspro. The Plan denied your request. The Plan says the enrollee 
has not tried the preferred drug. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Darzalex Faspro. Our physician 
reviewer found that the enrollee has multiple myeloma. The Plan requires a trial of Velcade before they will 
approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no 
documentation provided indicating that the Plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you do not have any other way to your 
appointments. The Plan denied your request. The Plan says your benefit only allows 50 miles. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
The file shows that transportation over 50 miles was requested. We looked at your request, the records in the 
case file, and the rules. Your plan only covers trips for up to 50 miles. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
1, 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 documents do not support this level of care. 
 
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 99223 is "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 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 the review has determined that 
code 99223 was not supported in the medical records. The review has determined that the records did not 
support a comprehensive history. 
 
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 initial hospital care (procedure code 99223) rendered on June 1, 2022.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says based on Medicare guidelines the enrollee 
does not meet all the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services billed with the following codes: 
90471, 73562, 70486, 72125, 90471, and 73562 billed for date of service December 8, 2022. 
 You asked the Plan to pay for codes 90471, 73562, 70486, 72125, 90471, and 73562. You say that these 
services are covered and were medically necessary. The Plan denied your request. The Plan says no separate 
payment can be made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. Medicare rules also state that services with a status indicator of Q3 
are packaged into the APC rate and not separately paid.  
 
Codes 90471, 73562, 70486 and 72125 have a status indicator of Q3, so payment for those codes is included in 
the composite APC rate and no separate payment is made.  In regards to codes 70486 and 72125, these codes 
have a status indicator of Q1, meaning that they are STV codes.  They were billed on the same claim as code 
99284, which has a status indicator of V.  That means that these two codes cannot be paid separately either.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 70486, 72125, 90471, and 73562 have not been met. Therefore, we decided that the Plan 
does not have to pay for emergency room services billed with the following codes: 90471, 73562, 70486, 
72125, 90471, and 73562 billed for date of service December 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on October 12, 2021, to 
October 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says payment for these services is not supported. 
 
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 inpatient hospital care provided 
have been met. Specifically, an itemized bill summary has not been provided for review. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided on October 12, 2021, to October 22, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH can render services that cannot 
be rendered at a lower level of care: The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-Plan referral for a second opinion to the 
cancer center to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an out-of-plan referral. You say that the requested provider has specialist 
that can provide further treatment options for your condition, and you feel that an out-of-Plan medical opinion 
is necessary. The Plan denied your request. The Plan says you must use in-network providers to receive 
services/care. This service is available by a provider in your network. You may obtain a second opinion from 
an in-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 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 
an out-of-Plan referral for a second opinion to the cancer center to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator. 
 
You asked the Plan to pre-approve a Life2000 home mechanical ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 home mechanical ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine 
with average volume-assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 a Life2000 home mechanical ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Life2000 home mechanical ventilator.