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 requesting an expedited reconsideration 
for the denial of an IRF admission. The Plan denied your request. The Plan says the service requested is not 
supported based on the records received. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that the enrollee would meet criteria for admission 
to an acute inpatient rehabilitation facility. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. The Plan denied your request. The Plan 
says you have exhausted your transportation benefit. 
 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 Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on October 11, 2022. 
 
You asked the Plan to pay for debridement of nails. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement of nails 
provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 27, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were never seen by 
the provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including doctors office visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist office visit provided on February 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need the rehab to gain strength and be able to 
walk again. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 would be the appropriate level of care to meet 
the needs of the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the admission 
criteria for 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. 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 pay for the routine eye exam provided on February 2, 2023. 
 
You asked the Plan to pay for the routine eye exam. You say that the visit was not billed as a routine eye exam 
as you requested. You say the visit was billed as a medical eye exam. The Plan denied your request. The Plan 
says that the benefit has been 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 provide documentation showing a routine eye exam had 
previously been paid. This means we are unable to determine if the benefit has been exhausted. Therefore, we 
decided that the Plan has to pay for the routine eye exam provided on February 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(K0856) and related accessories (E0950, E0953, E1002, E1028, E2300, E2310, E2363, E2605, E2620). 
 
You asked the Plan to pre-approve the group 3 power wheelchair and related accessories. You say that the 
medical documentation provided supports the need for the requested items. The Plan denied your request. The 
Plan says the enrollee's needs can be met with a Group 3 power wheelchair with no power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair represented by code 
K0856 is covered when the criteria referenced in the Medicare rules section have been met. Medicare rules also 
say that if the power wheelchair base is not covered, then related accessories will be denied. 
 
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 group 3 power wheelchair and 
related accessories. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found the enrollee is not at high risk for skin breakdown, does not use a catheter and does not have spasticity 
impairing her positioning. She has adequate upper body strength to manage standard power drives. 
 
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 group 3 power wheelchair and related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single 
power option (K0856) and related accessories (E0950, E0953, E1002, E1028, E2300, E2310, E2363, E2605, 
E2620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861 and 95870 billed for date of 
service May 24, 2022. 
 
You asked the Plan to pay for procedure codes 51785, 95861 and 95870. You say that intraoperative 
monitoring is the utilization of sensory and motor monitoring techniques that help protect patients during 
surgical interventions. You say that Medicare covers these codes with the diagnosis billed and the claim should 
be reprocessed for reimbursement. The Plan denied your request. The Plan says procedure codes 51785, 95861 
and 95870 are not supported by the medical records submitted. 
 
  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 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. The CPT Code Manual definition of code 95861 is needle 
electromyography; 2 extremities with or without related paraspinal areas. The CPT Code Manual definition of 
code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles 
(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. 
 
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 procedure codes 51785, 95861 and 95870. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the procedure report does not include documentation of a needle EMG of the anal or urethral sphincter. 
The procedure report also does not include documentation of a needle EMG of 2 extremities or a needle EMG 
limited study of the muscles in 1 extremity or non-limb. Therefore, the procedures 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 procedure codes 51785, 95861 and 95870 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 51785, 95861 and 95870 billed for date of 
service May 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS Oral Brush CDx Biopsy test (88104, 88305, 88312, 88361) 
provided on April 11, 2022. 
 
You asked the Plan to pay for the WATS Oral Brush CDx Biopsy test. You say that this test should not be 
denied as experimental/investigational. The Plan denied your request. The Plan says that this test has not been 
proven to be effective in the setting of an unchanged chronic oral plague lesion. 
 
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. In this case no medical records beside the test report are included in the file to 
review medical necessity. There is no documentation showing the Plan attempted to obtain this information. 
Without medical records we are unable to verify if the Plans denial is correct. Therefore, we decided that the 
Plan has to pay for the WATS Oral Brush CDx Biopsy test (88104, 88305, 88312, 88361) provided on April 
11, 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 pre-approve sinus augmentation with bone or bone substitutes 
(D7951). 
 
You asked the Plan to pre-approve the dental service. You say that you are requesting reconsideration for the 
denial of sinus augmentation. The Plan denied your request. The Plan says the service is a non-covered code. 
 
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 sinus 
augmentation with bone or bone substitutes (D7951).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute 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. There is not reasonable expectation that the 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on January 27, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on January 27, 2023.
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 the services are medically necessary to 
give the enrollee the best outcome to return to their prior level of function. The Plan denied your request. The 
Plan says there is no advantage in moving the enrollee from the current acute care hospital 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 appears to be somewhat unstable still and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Completion of treatment at the current facility is 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 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 pay for an office visit provided on October 21, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 21, 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 the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current hospital until such time no acute 
services are required and then be transferred to a lower level of care for any ongoing long term care needs.  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.