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 were independent before your hospitalization 
and you want to return to being independent The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting 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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does 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 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: 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 meets the full criteria for an inpatient 
acute rehab stay, which is needed for rehabilitation to maximize their potential to return to their previous level 
of independence. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting 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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does 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 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: 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 requires prolonged and 
intensive skilled services that are not available at a lower level of care. You say that the enrollee requires 
oversight and management by physicians as well as care by a registered nurses with a focus on recovery. The 
Plan denied your request. The Plan says an LTACH admission 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752) and core buildup (D2950) for 
tooth #21. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental procedures are 
necessary because the enrollee is not able to wear any prosthesis. The Plan denied your request. The Plan says 
the denial of authorization for these services is correct, because they are splinting procedures. 
 
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 retainer crown and the core buildup is not medically necessary. Our physician reviewer found that the 
narrative from the provider asking for reconsideration of the treatment of the existing bridge as the enrollee 
cannot tolerate wearing a denture due to a severe gag-reflex. There was also a periapical x-ray included that 
shows teeth #18 and #20 with existing root canal treatment with the teeth already prepped for a bridge. The 
teeth have moderate to severe bone loss. The x-ray included is grainy in appearance and it is difficult to see the 
root canal filling material. 
 
There are large posts in teeth #18 and #20. The x-ray shows a partial view of tooth #21. Due to the poor 
resolution of the x-ray included I am unable to make a determination whether the retainer crown and core 
buildup are medically reasonable or necessary for tooth #21. A diagnostic x-ray would need to be sent in. 
 
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 a retainer crown (D6752) and core buildup (D2950) for tooth #21.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) and X-ray imaging services (72020, 
72040) provided on August 10, 2023. 
 
You asked the Plan to pay for an office visit and X-rays. You say that the services at issue were a necessity for 
your care. The Plan denied your request. The Plan says rules for payment for chiropractic services have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for an office visit (99203) and X-ray imaging services (72020, 72040) 
provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power 
options and accessories (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2322, E2351, E2377, E2603, 
K0842). 
 
You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options and accessories. 
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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 2 power wheelchair with 
multiple power options and accessories. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, 
have spasticity or require an alternative means of managing power drive. 
 
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 group 2 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair 
with multiple power options and accessories (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2322, 
E2351, E2377, E2603, K0842).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do 
not show that the enrollee's vascular status has been optimized. The Ankle Brachial Index was abnormal (below 
1). The review has determined that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy (99183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466), 12 months. 
 
You asked the Plan to pre-approve the continued use of a ventilator. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the records do not demonstrate that the enrollee 
has failed a bilevel positive airway pressure (BiPAP) when at your baseline breathing. The Plan also says that the requested renewal appears to be requested in an average volume assured pressure support (AVAPS) mode 
with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. 
 
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 the continued use of a ventilator. Our 
reviewer says that the request for continued use of a ventilator is not medically necessary. Our physician 
reviewer found the provided documentation indicates the enrollee was admitted with chronic obstructive 
pulmonary disease (COPD) exacerbation and pneumonia and treated appropriately and with bilevel positive 
airway pressure (BIPAP) therapy, which improved the enrollees course. The reviewer found that the enrollee 
did not fail BIPAP although showed continued initial hypercapnia. Therefore, the reviewer found that the 
request for continued use of a ventilator 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 continued use of a ventilator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued use of a home ventilator (E0466), 12 months.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on May 17, 
2023, and May 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON services. You say that you believe that you are a participating provider 
with the Plan, and you do not require authorization for these services. The Plan denied your request. The Plan 
says the rendering provider is not part of the Plan's network. Authorization is required for OON services.  
 
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 reviewed the evidence presented and find that it is not sufficient to prove network 
provider status with this specific Medicare plan. 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 outpatient mental health 
services provided on May 17, 2023, and May 24, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve CT scan of the heart with quantitative evaluation or coronary calcium. You 
say that this is medically necessary. The Plan denied your request. The Plan says quantitative calcium scoring 
is not a covered service and will be denied as not medically necessary. 
 
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 CT scan of the heart with quantitative 
evaluation or coronary calcium. Our reviewer says that there is insufficient support in the peer-reviewed 
literature demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of 
coronary calcium in guiding optimal management of this patient. Our physician reviewer found CT imaging of 
the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this patient's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart with quantitative evaluation or coronary calcium have not 
been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), heart, 
without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service May 17, 
2022.  You asked the Plan to pay for procedure code 87798. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. 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.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultraviolet (UV) light therapy system (E0691), provided 
on May 5, 2023. 
 
You asked the Plan to pay for a UV light therapy system. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no documentation of psoriasis in the enrollee's clinical 
documention. 
 
The Plan must follow Medicare rules. Medicare rules say that UV light therapy systems are covered for 
selected patients with generalized intractable psoriasis. Using appropriate consultation, the MAC should 
determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., 
outpatient department of a hospital.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a UV light therapy system have not been met. Therefore, we decided that the Plan does not have to 
pay for an ultraviolet (UV) light therapy system (E0691), provided on May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service February 11, 
2022.  
 
You asked the Plan to pay for procedure code 87798. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. 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.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service February 11, 2022.
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 reconsideration of denied 
authorization. The Plan denied your request. The Plan says 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute 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 continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that she 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.