Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 27, 
2023, to May 26, 2023. 
 You asked the Plan to pay for SNF care. You say that the services should be paid for under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 pay for skilled nursing facility (SNF) care provided from April 27, 2023, to May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair (K0005) and additional 
items and accessories (codes E2201, E2203, E1225, E0990 x2, K0040 x2, E2211 x2, E2213 x2, E0973 x2, 
K0108 x2, E0971 x2, E0978, E2620, E0955, E1028, E2607, and E0983). 
 
You asked the Plan to pre-approve an ultra-lightweight wheelchair and additional items and accessories. You 
say that the patient would benefit from the requested motorized wheelchair. The Plan denied your request. The 
Plan says the patient has a power wheelchair that is working. 
 
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 ultra-lightweight wheelchair and 
additional items and accessories. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the records indicate the additional power 
wheelchair is requested primarily for "transport to community settings" and not for participation in mobility 
related activities of daily living (MRADLs) such as toileting, feeding, grooming, and bathing in customary 
locations within the home. Our reviewer also found that the provided records do not document that the patient's 
present power wheelchair has been lost, stolen, irreparably damaged in a specific accident or natural disaster, or 
has reached its reasonable useful lifespan to meet Medicare criteria for replacement.  
 
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 ultra-lightweight wheelchair and additional items and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair 
(K0005) and additional items and accessories (codes E2201, E2203, E1225, E0990 x2, K0040 x2, E2211 x2, 
E2213 x2, E0973 x2, K0108 x2, E0971 x2, E0978, E2620, E0955, E1028, E2607, and E0983).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1230). 
 
You asked the Plan to pre-approve a power operated vehicle. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 power operated vehicle. Our reviewer 
says that the power mobility device (E1230) is not medically necessary. Our physician reviewer found there is 
a lack of clinical documentation indicating your level of mobility and physical examination findings, 
specifically with regards to motor strength in the upper and lower extremities. You are noted to have dyspnea 
on exertion, but there is no indication that you cannot use a cane or walker for assistance with mobility or 
propel a manual wheelchair in the home setting. Our reviewer also found that there is a lack of information as 
to whether you can safely operate the requested power mobility device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (E1230).
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 is aware of the denial on the 
authorization request for inpatient rehabilitation, and is requesting an appeal. The Plan denied your request. 
The Plan says the enrollee does not meet all of the requirements.  
 
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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found 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. Our physician reviewer also found that 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - all four quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you need this dental 
cleaning. The Plan denied your request. The Plan says x-rays do not show noticeable bone loss or show or that 
there is a hard substance built up on the root of the tooth. 
 
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 periodontal 
scaling and root planing 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 periodontal scaling and root planing. 
Our reviewer says that this dental work is not medically necessary. Our physician reviewer found the upper 
arch does not show any appreciable bone loss in either the right or left quadrants and therefore would not qualify for the requested procedures. The lower arch has one affected tooth (#21) on the left side and two on 
the right (#30 and 31) that show loss of attachment indicated by bone loss. 
 
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 periodontal scaling and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing - all four quadrants.
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 weal and unstable to walk from being in the 
intensive case unit needing inpatient rehabilitation to build back your strength to be independent again. The 
Plan denied your request. The Plan says you must have completed your full coarse of treatment in the referring 
hospital and when medically stable you may continue therapy at a lower level of care.  
 
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. The medical records 
support 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. It 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 3, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on June 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services billed with codes 97110, 97530, and 
97535 for date of service July 17, 2023. 
 You asked the Plan to pay for the therapy services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F01.B0, defined 
as vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and 
anxiety. This code is not an appropriate primary diagnosis as the code has a Code first note indicating to code 
the underlying condition first. Based on this information, we decided that Medicare rules for payment of this 
claim have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services 
billed with codes 97110, 97530, and 97535 for date of service July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair (K0005) provided on July 19, 2023. 
 
You asked the Plan to pay for the wheelchair. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair (K0005) provided on July 
19, 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 due to the enrollee's complex medical issues they 
need therapy services before returning home. The Plan denied your request. The Plan says the records do not 
show that the services delivered are reasonable and necessary for the enrollee's illness. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer provided on August 12, 2023. 
 
You asked the Plan to pay for the nebulizer. You say that the enrollee may choose their provider. 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 the nebulizer provided 
on August 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 billed for date of service August 24, 
2023. 
 
You asked the Plan to pay for procedure code 81479. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that any claim lines billed with the GZ modifier are automatically denied. 
 
We find that CPT code 81479 is not supported. Specifically, the code has been reported with the GZ modifier. Based on this information, we decided that Medicare rules for coverage of procedure code 81479 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 billed for date of 
service August 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service July 26, 
2023.  
 
You asked the Plan to pay for procedure code 64488. You say that these services are 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 64488 is 1. The MAI value for this code is 3. You billed 2 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 64488 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64488 billed for date of service July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service August 24, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that the services at issue were a medical 
necessity for the enrollee. 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 88341 is 13. The MAI value for this code is 3. You billed 15 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service August 24, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a liver transplant evaluation. 
 
You asked the Plan to pre-approve a liver transplant evaluation. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that adult liver transplantation when performed on 
beneficiaries with end- stage liver disease other than hepatitis B or malignancies is covered under Medicare when performed in a facility which is approved by the Centers for Medicare & Medicaid Services (CMS) as 
meeting institutional coverage criteria. 
 
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 liver transplant evaluation. Our 
reviewer says that the services are medically necessary. Our physician reviewer found justification for denial 
includes the fact that she is very encephalopathic (thus far unresponsive to lactulose) and the fact that she was 
offered hospice care. For the former, she also received fentanyl as an inpatient, and is on amytriptyline and 
gabapentin, which may be clouding the picture. Regardless, lack of response does not necessarily portend a 
poor outcome from liver transplant. Her mentation was sufficient to explain to the Hepatology team that she 
did not want to do. As to the issue of hospice, this was a recommendation made by the non-Hepatology/non-
Transplant team and they frequently are not as familiar with transplant eligibility criteria. The enrollee is sick 
and deconditioned (being addressed with Dobhoff feeding tube placement), but on review of all the clinical 
documentation, there is not a contraindication to liver transplantation. Indeed, she has demonstrated good 
compliance with sobriety since learning about her liver disease 8 years ago, which portends well for her. 
 
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 liver transplant evaluation have been met. Therefore, we decided that the Plan 
has to pre-approve a liver transplant evaluation.  
 
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.