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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has improved a bit in the skilled nursing 
facility, but needs more extensive therapy. The Plan denied your request. The Plan says based on the available 
information, admission to an IRF is not reasonable and 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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  Our reviewer found that the enrollees care needs can be met at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this request is medically necessary. The Plan denied 
your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. Our reviewer also found that there is 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, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fell and broke their hip, has had surgery, 
and is in need of inpatient rehabilitation to regain and continue independent life. The Plan denied your request. 
The Plan says based on the available information, admission to an IRF is not reasonable and 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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  Our reviewer also found that the enrollees care needs can be met at a lower level 
of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the documentation provided, coverage 
criteria has not been met. The Plan denied your request. The Plan says the services are 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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met 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: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment  includes modification and placement (D6056), and abutment supported 
porcelain/ceramic crown (D6058). 
 
 
 You asked the Plan to pre-approve the dental services. You say that the day after your knee surgery your tooth 
came out and there is now a big a space in your mouth. You also say that you need this service so you can chew 
on that side of your mouth.  The Plan denied your request. The Plan says  based on your records your dentist 
sent in, they did not tell us about the plan for all the teeth.  
 
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 dental services are not medically necessary. Our physician reviewer found from the limited supplied 
documentation it cannot be ascertained of the treatment is medically necessary. The only provided x-ray was 
one bite wing view of the right quadrant. The suggested implant was for tooth #30, which is seen as having an 
existing crown or very extensive restoration, and a prior root canal treatment. The x-ray view provided does not 
show the apical area of the tooth. There is no clear manner to access if tooth #30 required removal such that an 
implant could be placed. Without more information it is impossible to determine if the need for a particular 
procedure, as it is unclear as to why the natural tooth needed to be removed. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body: endosteal implant (D6010), prefabricated 
abutment  includes modification and placement (D6056), and abutment supported porcelain/ceramic crown 
(D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20553, 77002, and 99214 rendered on June 
29, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 20553: 
 
Injection(s); single or multiple trigger point(s), 3 or more muscles 
 
CPT 77002: 
 
Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List 
separately in addition to code for primary procedure) 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
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 procedure report does not 
include sufficient documentation to verify the procedures performed. The medical records documents that the 
site was verified and marked, with vitals noted. Trigger points cannot be verified in the documentation 
submitted. Therefore, CPT 20553 and CPT 77002 were not supported.  
 
In terms of CPT 99214, the records describe that the enrollee presented to the office for evaluation of lower 
back pain. A trigger point injection was performed. The record also describes the enrollee has received 
injections in the past and has provided relief. In this case, a significant, separately identifiable service cannot be 
verified in medical record, and therefore procedure and modifier would not be reported separately. 
 
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 20553, 77002, and 99214 rendered on June 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service April 12, 2023. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the billing of code 99285. 
The Plan denied your request. The Plan says code 99285 is not supported by the medical record.  The enrollee's 
presenting problem was not a high/immediate threat to life.  As a result, this code was down-coded to 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the enrollee was evaluated in the emergency department 
for malaise and weight loss.  The documented history and physical are appropriate.  The documented medical 
decision making is not of high complexity.  While the differential diagnosis was broad, the enrollee was stable, 
and his condition posed no immediate threat to life or function.  As such, the billing of CPT 99285 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthroscopy with a partial meniscectomy. 
 
You asked the Plan to pre-approve an arthroscopy with a partial meniscectomy. You say that his procedure 
would benefit the enrollee. The Plan denied your request. The Plan says the enrollee has osteoarthritic. 
 
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 an arthroscopy with a partial 
meniscectomy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Moreover, there is 
imaging evidence of osteoarthritis in the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an arthroscopy with a partial meniscectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an arthroscopy with a partial meniscectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like a fast appeal of this 
decision. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
intelligent volume-assured pressure support (iVAPS) mode with Auto-expiratory positive airway pressure 
(EPAP) that could be delivered by BiPAP is not covered.  
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found this enrollee has COPD, and is 
on chronic treatment with narcotics and benzodiazepines. The enrollee has been hospitalized twice in the last 
few months with acute on chronic hypercarbic respiratory failure, both times requiring intubation. Our reviewer 
found that there are no pulmonary function tests to confirm the severity of the COPD. Chronic carbon dioxide 
retention seems very likely, although there is no arterial blood gas (ABG) analysis done while stable. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. Our physician reviewer also found that 
this enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as 
an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 You asked the Plan to pre-approve Monoferric. You say that the request is medically necessary. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
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 Monoferric. Our reviewer says that the 
criteria for coverage of Monoferric have not been met. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives, Infed and Venofer. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the Plan's preferred drug(s). 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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for scleral contact lenses (V2531) provided on February 
24, 2023.  
You asked the Plan to pay more for scleral contact lenses (V2531). You say that the multiple eye specialists 
you have seen all have concluded that the scleral lenses are your only option. You also say you are on a limited 
income and cannot afford the costs of the lenses. The Plan denied your request. The Plan says this benefit was 
exhausted with this date of service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $300 per year for the 
following contact lenses. Based on this information, we decided that the Plan's rules for coverage of scleral 
contact lenses (V2531) have not been met. Therefore, we decided that the Plan does not have to pay more for 
scleral contact lenses (V2531) provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the 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 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 the office visit provided on June 15, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EpiFix (Q4186 x 900 units), EpiCord (Q4187 x 900 
units), and application of skin substitute graft (11527 x 15 visits). 
 
You asked the Plan to pre-approve the application of EpiFix and EpiCord skin substitute. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the records did not specify 
that the wound had adequate circulation by physical examination or imaging, and that there was no 
osteomyelitis or soft tissue infection. 
 
The Plan follows Medicare rules. Medicare rules say that application of skin substitute grafts are recommended 
in the presence of a neuropathic diabetic foot ulcer or venous stasis ulcer that has failed treatment for up to 3 
months and has been unresponsive to appropriate wound 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 the application of EpiFix and EpiCord 
skin substitute. Our reviewer says that the requested application of EpiFix and EpiCord skin substitute is not 
medically necessary. Our physician reviewer found the provided medical documentation supports that since the 
end of April until the very end of September, your ulcer has reduced in size. The reviewer found that the 
medical documentation does not support that you are undergoing treatment for your lower leg edema, nor is 
there imaging or testing to prove that there is no underlying osteomyelitis. Finally, the progress notes do advise 
that you have undergone application of advanced skin substitutes and amniotic dressings in the past without 
resolution of their ulceration. Therefore, the reviewer found that the requested application of EpiFix and 
EpiCord skin substitute 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 application of EpiFix and EpiCord skin substitute have not been met. 
Therefore, we decided that the Plan does not have to pre-approve EpiFix (Q4186 x 900 units), EpiCord (Q4187 
x 900 units), and application of skin substitute graft (11527 x 15 visits).