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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says your condition does not meet Medicare guidelines for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care.  There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 10, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim should be paid at the in-network 
rate because the surgeon was in-network. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 10, 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 you need to regain strength before returning home. 
The Plan denied your request. The Plan says admission into an inpatient rehabilitation facility 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 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. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 24, 2023, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RestoreX penile traction therapy device. 
 
You asked the Plan to pre-approve the RestoreX penile traction therapy device. You say that the item should 
be covered. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the RestoreX penile traction therapy device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 14060-AS, 13152-AS, 11012-AS, 30140-
AS, 11011, 11011-AS, and 11011-AS-XS billed for date of service June 9, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not 
covered.  In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 
14060, 13152, 11011, 11012, and 30140. The Medicare Fee Schedule Database contains a surgical indicator of 
1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11011 
is a column II code to column I code 11012. Code 11011 has not been billed with an appropriate modifier to 
bypass the edit. 
 
Medicare rules say that submitted claims in which the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 3, unless there is evidence justifying the excess units. For CPT Code 11011-AS-XS, the 
MUE for CPT code 11011 is 2. The MAI value for this code is 3. You billed 3 units of this code, exceeding the 
MUE. The documentation does not show that the excess units were provided, correctly coded, and necessary. 
Based on this information, we decided that Medicare rules for coverage have not been met. Based upon this information, we find that Medicare coverage criteria for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 14060-AS, 13152-AS, 11012-AS, 
30140-AS, 11011, 11011-AS, and 11011-AS-XS billed for date of service June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing for for hemoglobin A1C billed for January 
16, 2023. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that glycated hemoglobin/protein testing is widely 
accepted as medically necessary for the management and control of diabetes and to assess hyperglycemia, a 
history of hyperglycemia or dangerous hypoglycemia. 
 
We looked at the file and Medicare rules. The file shows that the testing was not performed for a diagnosis of 
diabetes or to assess blood sugar levels. 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 the genetic 
testing for for hemoglobin A1C billed for January 16, 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 you still require hands on assistance from the nursing 
staff and therapy staff to get out of bed. You also say your provider says you will need closer medical 
management of your current medical needs and disease. The Plan denied your request. The Plan says you can 
receive the care you need at a skilled nursing 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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377). 

You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee is unable to self-propel, 
functionally weight shift or reposition herself putting her at risk of skin breakdown. The Plan denied your 
request. The Plan says that although there are three approved power options on this wheelchair, there is not a 
medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory and requires a power wheelchair for mobility and 
performing her basic daily activities. She cannot perform pressure relief independently due to upper extremity 
weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and 
positioning. She requires power elevating leg rests for positioning of her lower extremities and lower extremity 
spasticity and edema. The complexity of her seating and positioning needs necessitates a more complex group 
3 power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options via a joystick. These components are 
required to operate 3 or more power options on a group 3 power wheelchair. Therefore, the expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311) is 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 wheelchair accessories have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), a harness (E2313) and an expandable controller (E2377).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151) and home health 
occupational therapy (G0152). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
was previously independent with mobility and performing daily activities prior to her stroke. The enrollee has 
received home health physical and occupational therapies after her stroke and is currently living in an assisted 
living facility. The documentation indicates that physical and occupational therapies were discontinued due to a 
plateau with therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151) and home health occupational therapy 
(G0152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim and that the services requested are medically necessary. 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 pre-approve the 
dental services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x14). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records 
report that you are going to a wound clinic regularly and recent testing has ruled out osteomyelitis. Provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records do not 
support that the complexity of your conditions are such that a skilled nurse is required to provide additional 
services beyond those which have been approved. Records support that a re-evaluation of your condition is 
appropriate at the completion of the 12 approved visits with an order for more nursing services at that time, if 
indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x14).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care telehealth visit (code 99233) 
billed for date of service May 31, 2023. 
 
You asked the Plan to pay for code 99233. You say that you do not believe this code conflicts with any other 
charge. The Plan denied your request. The Plan says you have exceeded the frequency permitted for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that subsequent hospital care services are limited to 
one telehealth visit every 3 days.  In this case, you billed code 99233, which is a subsequent hospital visit, for 
date of service May 31, 2023.  The records show this was a telehealth visit.  However, you also billed a 
telehealth subsequent hospital visit on May 30, 2023.  This is within 3 days of the date of service at issue in this 
appeal. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care telehealth visit (code 99233) billed for date of service May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 18, 2023, to February 6, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says a 
PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is 
a preventive service and is not covered by the Plan. 
 
 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 on January 18, 2023, to February 6, 2023.